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1907 


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BUREAU  OF  THE  CENSUS 


v 


S.RD.NORTH^DIRECTOR 


Modes  of  Statement  of  Cause  of 

Death  and  Duration  of  Illness 

upon  Certificates  of  Death 


COMPARISON  OF  FORMS  NOW  IN  USE  IN 
THE  UNITED  STATES  AND  CERTAIN 
OTHER  COUNTRIES  AND  SUGGESTION 
OF  A  MODIFICATION  OF  THE  STANDARD 
CERTIFICATE  OF  DEATH  IN  ORDER  TO 
SECURE  UNIFORM  AND  DEFINITE  STATE- 
MENTS OF  CAUSES  OF  DEATH  £  £  <£  £  & 
&  &  #  £  CHECK  LIST  OF  REGISTRATION 
OFFICIALS,  REPORTS  AND  BULLETINS 


0f  (Eommm?  atd 


§;• 


BUREAU  OF  THE  CENSUS 
S.  N.  D.  NORTH  *  DIRECTOR 


Modes  of  Statement  of  Cause  of 

Death  and  Duration  of  Illness 

upon  Certificates  of  Death 


COMPARISON  OF  FORMS  NOW  IN  USE  IN 
THE  UNITED  STATES  AND  CERTAIN 
OTHER  COUNTRIES  AND  SUGGESTION 
OF  A  MODIFICATION  OF  THE  STANDARD 
CERTIFICATE  OF  DEATH  IN  ORDER  TO 
SECURE  UNIFORM  AND  DEFINITE  STATE- 
MENTS OF  CAUSES  OF  DEATH  Jk  &  j*  Jt  j* 
<£££,£  CHECK  LIST  OF  REGISTRATION 
OFFICIALS,  REPORTS  AND  BULLETINS 


nf  fflattuttm?  anb 


CENSUS   PUBLICATIONS   ON    MORTALITY  STATISTICS   SINCE 

1900. 


TWELFTH    CENSUS. 

Vital  Statistics,  Part    I — Analysis  and  Eatio  Tables. 

Vital  Statistics,  Part  II— Statistics  of  Deaths. 

Bulletin  No.  15.     A  discussion  of  the  Vital  Statistics  of  the  Twelfth  Census. 

[The  last  of  the  series  of  decennial  reports.  The  data  are  for  the  census  year  end- 
ing May  31,  1HOO,  and  are  based  upon  enumerators'  returns  from  the  nonregistration 
area  and  upon  transcripts  of  deaths  from  the  registration  records,  chiefly,  for  the 
registration  area.  Succeeding  reports  are  for  the  calendar  years  and  relate  to  the 
registration  area  only.] 


PERMANENT    CKNSl's. 


Mortality  Statistics,  1900  to  1904.     Five  years  in  one  volume. 

Mortality  Statistics,  1905.     Sixth  Annual  Report. 

Mortality  Statistics,  1906.     Seventh  Annual  Report.     In  preparation 


PAMPHLETS. 

No.    71.   (Circular)  Registration  of  Deaths. 

No.  100.  Legislative  Requirements  for  Registration  of  Vital  Statistics.     [Out  of  print. 

See  Nos.  71  and  104.] 

No.  101.  Practical  Registration  Mb^hot'ls.,1  ;:.:,'    ,' 
No.  102.  Relation  of  Physician?  to/Mgrtali^^tjita^Jrics. 
No.  103.  Medical  Education,  in  VitaJ  S.tatis^igs.    .[O.ut  orf  print.]  ^ 

No.  104.  Registration  o/ ^iiJtl5i*kEfd:i|eath^  :      I   *\'  '; 
No.  105.  Statistical  Treatment VA  ^au§ei  of»I>eath/ "  •  *•  * 
No.  10(3.  Extension  of  the  Registration  Area  for  Births  and  Deaths. 
No.  107.  Modes  of  Statement  of-  Cause  of  Death  and  Duration  of  Illness  upon  Certifi- 
cates of  Death. 


Manual  of  International  Classification  of  Causes  of  Death. 

NOTE. — Any  publications  now  in  print  may  be  obtained  upon  application  to  the  Director  of  the 

Census. 


CONTENTS. 


Page. 

Introductory 5-12 

Important  subjects  requiring  united  action 6 

Uniform  mode  of  statement  of  cause  of  death  indispensable 9 

Modification  of  the  standard  blank  proposed 10 

Personnel  of  American  registration  service 11 

Extension  of  the  registration  area 11 

Modes  of  statement  of  cause  of  death  and  duration  of  illness  upon  certificates 

of  death 13-39 

United  States: 

A.  Standard  certificate  of  death 14 

B.  Modified  standard  certificate  of  death  _  _• .. .  16 

C.  Old  forms  used  by  Census 19 

D.  Miscellaneous  forms 21 

Foreign  countries: 

1.  France 28 

2.  Germany 30 

3.  Great  Britain  and  Colonies 31 

4.  Italy 33 

5.  Japan « 33 

6.  Sweden 35 

7.  Switzerland .• 35 

Terminology  and  arrangement  of  terms  employed  upon  certificates  of  death  to 

denote  causes  of  death 40 

Definitions  of  more  important  terms 41 

Definitions  of  less  important  terms 48 

Application  of  terms  in  certifying  causes  of  death 49 

( 1 )  Deaths  from  disease 50 

(2)  Deaths  from  violence .    58 

Duration  of  illness 61 

Conclusions  and  recommendations 62-67 


Appendix  A. — Circular  of  announcement  of  organization  of  American  associa- 
tion of  registrars  of  vital  statistics 69-70 

Appendix  B. — Check  list  of  registration  officials,  and  of  reports  and  bulletins 
containing  vital  statistics,  in  the  United  States:  1907 71-81 


Map  showing  states  in  which  the  standard  certificate  of  death  has  been 
adopted  (or  recommended  in  nonregistration  states')  by  the  state  authori- 
ties: 1907 7 

(3) 

M82445 


INTRODUCTORY. 

This  pamphlet  has  been  prepared  by  the  Bureau  of  the  Census  for 
presentation  to  the  registration  officials  of  the  United  States  at  the 
initial  session  of  their  national  organization,  which  will  be  formed  as 
a  Section  of  the  American  Public  Health  Association  at  its  meeting  to 
be  held  at  Atlantic  City,  N.  J.,  from  September  30  to  October  4, 1907. l 

The  cooperation  of  the  American  Public  Health  Association  and  the 
Bureau  of  the  Census  has  already  been  fruitful  of  practical  results — 
among  them  the  formulating  of  the  essential  requirements  of  an  effect- 
ive law  for  the  registration  of  deaths,  since  carried  into  successful 
operation  in  many  states,2  and  the  preparation  of  a  standard  certificate 
of  death — and  has  received  the  express  approval  of  the  Congress  of 
the  United  States  by  a  joint  resolution  approved  February  11,  1903, 
the  concluding  portion  of  which  is  as  follows: 

Whereas  the  American  Public  Health  Association  and  the  United  States  Census 
Office  are  now  cooperating  in  an  effort  to  extend  the  benefits  of  registration  and  to 
promote  its  efficiency  by  indicating  the  essential  requirements  of  legislative  enact- 
ments designed  to  secure  the  proper  registration  of  all  deaths  and  births  and  the 
collection  of  accurate  vital  statistics,  to  be  presented  to  the  attention  of  the  legisla- 
tive authorities  in  nonregistration  states,  with  the  suggestion  that  such  legislation  be 
adopted:  Now,  therefore, 

Resolved  by  the  Senate  and  House  of  Representatives  of  the  United  States  of  America  in 
Congress  assembled,  That  the  Senate  and  House  of  Representatives  of  the  United 
States  hereby  expresses  approval  of  this  movement,  and  requests  the  favorable  con- 
sideration and  action  of  the  state  authorities,  to  the  end  that  the  United  States  may 
attain  a  complete  and  uniform  system  of  registration. 

The  organization  of  a  special  Section  of  the  Association,  devoted 
entirely  to  vital  statistics,  and  embracing  in  its  membership,  as  it  is 
hoped,  the  entire  registration  service  of  the  United  States,  should 
greatly  facilitate  the  continuance  of  this  cooperation,  and  should 
enable  effective  concerted  -action  to  be  taken  upon  many  practical 
questions  affecting  the  collection  and  presentation  of  vital  statistics, 
which  are  now  in  a  chaotic  and  exceedingly  unsatisfactory  condition. 

1  See  Circular  of  Announcement,  Appendix  A. 

2  See  Census  circular  No.  71  containing  paper  of  the  Committee  of  the  American  Public  Health 
Association  on  Demography  and  Statistics  in  their  Sanitary  Relations,  entitled  ''The  Essential 
Requirements  of  a  Law  for  the  Registration  of  Deaths  and  the  Collection  of  Mortality  Statistics;" 
Census  pamphlet  No.  104,  Registration  of  Births  and  Deaths — Drafts  of  Laws  and  Forms  of  Certifi- 
cates; and  Census  pamphlet  No.  106,  Extension  of  the  Registration  Area  for  Births  and  Deaths— A 
Practical  Example  of  Cooperative  Census  Methods  as  applied  to  the  State  of  Pennsylvania.    These 
will  be  sent  by  the  Director  of  the  Census  upon  request. 

(6) 


IMPORTANT    SUBJECTS    REQUIRING    UNITED    ACTION. 

Some  of  the  important  subjects  requiring  agreement  and  upon 
which  action  may  well  be  taken  by  the  representative  organisation  of 
American  registrars,  are  as  follows: 

1.  Legislation  for  the  improvement  of  vital  statistics,  (a)  Federal, 
(&)  state,  and  (c)  municipal.     The  "Essential  Requirements"  for  the 
registration  of  deaths,  which  have  stood  the  test  of  actual  experience 
for  some  six  }Tears,  should  be  revised,  if  any  revision  be  necessary,  and 
reaffirmed.     State  laws  enacted  during  recent  years  should  be  com- 
pared in  connection  with  the  essential  requirements,  and  the  condi- 
tions of  their  failure  or  success  pointed  out.     Similar  criteria  should 
be  framed  for  the  registration  of  births.     No  state  or  city 'has  yet 
been  accepted  by  the  Bureau  of  the  Census  as  having  the  minimum 
standard  of  completeness  (only  90  per  cent)  of  birth  registration;  it  is 
believed  that  a  beginning  may  be  made  at  an  early  date  and  a  "  regis- 
tration area  for  births "  be  constituted.     The  drafts  of  laws  recom- 
mended by  the  Bureau  of  the  Census  should  be  remodeled,  simplified 
as  much  as  possible,  and  effective  alternative  plans  suited  to  special 
conditions  in  the  West  and  South  be  arranged.     For  cities  in  the  non- 
registrat^ion  states  a  model  city  ordinance  for  the  registration  of  births 
and  deaths  should  be  prepared,  so  that  a  beginning  of  registration  can 
be  made  without  waiting  for  the  sometimes  tardy  coming  of  ^general 
state  legislation.     The  formation  of  a  Section  of  municipal  health 
officers  at  the  present  meeting  of  the  Association  should  be  of  impor- 
tant service  in  this  connection,  and  a  special  committee  might  well  be 
appointed  by  it  to  cooperate  with  the  committee  of  the  Section  of 
vital  statistics. 

2.  Administrative  methods  should  be  compared,  and  a  higher  standard 
of  general  efficiency  in  collecting  and  handling  registration  returns  be 
attained.     There  should  be  absolute  agreement  as  to  what  constitutes 
a  birth,  a  stillbirth,  and  a  death,  for  registration  purposes,  in  the  entire 
country.1     At  present  there  is  great  lack  of  uniformity  in  this  respect. 
Some  registrars  include   stillbirths   in  deaths;    some  exclude  them. 
Some  registrars   include   stillbirths   in  births;    some  exclude  them. 
The  term  "  stillbirth"  is  undefined,  and  means  one  thing  in  one  place 
and  another  in  another;  yet  upon  its  precise  definition  depends  uni- 
formity in  the  statement  of  births  and  deaths.     Sometimes  deaths  in 
institutions  or  deaths  of  transients  or  nonresidents  are  included  in 
total  deaths,  and  sometimes  they  are  excluded;  sometimes  deaths  in 
institutions  located  without  a  city  are  included  in  its  statistics.     When 
it  comes  to  the  classification  of  causes  of  death,  even  when  the  Inter- 
national Classification  is  in  use,  there  is  chaos  indeed;  the  same  deaths 
compiled  in  two  or  three  separate  offices,  as  sometimes  happens,  may 

1  Resolutions  containing  definitions  of  these  elements  of  vital  statistics  will  bo  presented. 


show  quite  different  results,  largely  due  to  the  lack  of  an  accepted  uni- 
form method  for  the  disposition  of  joint  causes  and  an  identical  form 
of  statement  by  physicians  and  coroners  upon  their  certificates. 
Imperfect  data  are  not  uniformly  corrected,  and  no  general  system  of 
checks  or  tests  is  in  operation  whereby  a  registrar  may  be  assured  of 
the  substantial  completeness  of  his  results.  All  of  these  unfortunate 
conditions  can  be  remedied  by  the  cooperation  of  the  registrars  them- 
selves, if  once  organized  into  a  coherent  body,  and  there  is  no  other 
way,  under  our  system  of  government,  by  which  they  can  be  materially 
improved. 

3.  Uniform  blanks  should  be  employed  for  the  collection  of  the  fun- 
damental data  upon  which  the  vital  statistics  are  based.  In  1900  only 
two  states  in  the  Union  employed  the  same  form  of  certificate  of  death. 

States  in  which  the  standard  certificate  of  death  has   been  adopted  (or  recommended  in 
nonregistration  states)  by  tJte  stale  authorities:  1907. 


As  a  result  of  the  movement  begun  by  the  Association  a  standard  blank 
was  prepared  and  recommendjed  by  the  Bureau  of  the  Census  for  gen- 
eral adoption.  It  is  now  in  use  in  many  states  and  cities,  including 
all  of  the  registration  states  except  a  few  of  the  older  ones  that  already 
possessed  forms  containing  all  of  the  essential  items,  and  which  they 
were  reluctant  to  abandon  for  the  reason  that  their  filing  cabinets  or 
methods  of  clerical  work  were  especially  adapted  to  the  old  forms  in 
use.  Only  two  states,  both  included  in  the  nonregistration  area,  have 
blanks  recommended  by  their  state  authorities  that  do  not  include  all 
of  the  information  required  for  the  annual  reports  on  Mortality  Statisr 
tics  prepared  by  the  Bureau  of  the  Census,  and  it  is  hoped  that  with 
the  adoption  of  effective  laws  in  those  states  the  standard  blank  will 
be  introduced.  Many  cities,  however,  continue  to  use  very  defective 


8 

forms,  and  it  would  be  desirable  for  them,  where  the  matter  is  entirely 
under  local  control,  to  adopt  the  standard  certificate. 

Even  with  the  standard  blank,  however,  there  is  beginning  to  be  a 
diversity  of  arrangement  and  mode  of  statement  of*  certain  items,  so 
that  the  condition  of  actual  uniformity  may  be  lost.  It  would  be  well 
for  a  general  agreement  to  be  reached  as  to  the  desirability  of  any 
modification  of  it,  and  then  that  the  standard  blank  should  be  adopted 
and  maintained  in  use  in  the  standard  form  so  far  as  all  of  the  essen- 
tial items  are  concerned.  There  is,  of  course,  provision  for  special 
additional  data  required  by  the  laws  of  certain  states. 

The  most  important  items  concerning  which  the  form  of  statement 
may  perhaps  be  altered  with  advantage  are  the  following: 

(a)  Occupation. — While  this  item  should  afford  some  of  the  most 
practically  useful  information  derived  from  mortality  statistics,  it  does 
not  do  so  at  present.  A  complete  study  of  the  subject  by  an  author- 
ized committee,  and  with  the  aid  of  all  who  are  interested  in  statistics 
of  the  mortality  of  occupations,  should  be  made  and  an  improved 
schedule  formulated,  if  one  not  too  cumbrous  can  be  devised,  that  will 
enable  a  beginning  to  be  made  in  the  collection  of  satisfactory  material.1 

(5)  Cause  of  death. — This  is  even  more  fundamental  than  occupation, 
and  this  pamphlet  has  been  especially  devoted  to  this  subject  as  the 
most  urgently  important  of  any  that  can  come  before  the  organized 
association  of  registration  officials,  and  also  one  that  they  are  quite 
able  to  radically  reform. 

4.  Uniform  methods  of  presentation  of  data  relating  to  vital  statis- 
tics should  be  adopted.     Registration  reports  and  bulletins  of  states 
and  cities  should  be  readily  comparable  with  each  other  and  with  the 
annual  Mortality  Reports  of  the  Bureau  of  the  Census.     Each  class  of 
report  or  bulletin  has  its  own  field  of  usefulness  and  may  go  into 
greater  or  less  detail  in  certain  directions,  as  may  be  necessary  for  its 
own  specific  purpose,  but  when  the  results  come  together  they  must 
harmonize.     Otherwise  our  statistics,  as  a  nation,  will  become  discred- 
ited and  the  old  gibe  that  "One  can  prove  anything  by  statistics"  will 
seem  to  be  true. 

5.  Standard   tables   showing  the  most  important  results  for  each 
year  of  registration  should  be  prepared  for  each  state  and  city.     The 
past  results  of  registration  in  the  United  States  should  be  made  avail- 
able for  convenient  reference,  no  matter  how  imperfect.     The  figures 
should  be  critically  examined,  and  explanatory  notes  made  of  changes 
of  methods  of  collection  or  compilation  of  data,  probable  degree  of 
completeness  of  registration,  etc. ,  so  that  users  of  statistics  may  know 

1  A  form  will  be  submitted  merely  as  a  basis  of  discussion  and  so  that  definitive  action  may  be 
taken  in  1908  without  waiting  another  year  for  the  report  of  the  special  committee  in  charge  of  the 
subject.  It  is  desirable  that  all  changes  in  the  standard  blank  be  made  at  the  same  time.  In  the 
meantime  it  is  urged  that  special  attention  be  given  to  the  subject  by  statisticians.  A  symposium 
on  "Occupations"  is  planned  in  the  American  Statistical  Association,  in  which  the  requirements  of 
the  schedule  and  instructions  on  occupations  may  be  discussed  from  the  several  points  of  view  of 
population,  industrial  (manufactures),  and  vital  statistics. 


9 

just  what  the  sources  of  information  are  and  the  actual  value  of  the 
published  figures.  As  a  basis,  the  items  contained  in  the  international 
tables  published  by  the  French  government  (Statistique  generate  de  la 
France,  Tome  XXXII,  1902)  may  be  taken,  namely,  population  at  each 
census  since  the  beginning  of  registration  and  estimated  populations 
for  intercensal  years,  number  of  marriages,  living  births,  stillbirths, 
and  deaths  (exclusive  of  stillbirths)  for  each  year,  with  rates  per 
1,000  enumerated  or  estimated  population.  The  French  tables  con- 
tain data  for  only  five  American  states,  Connecticut  (1848-1900),  Mas- 
sachusetts (1849-1900),  Maine  (1892-1898),  Michigan  (1868-1899),  and 
Rhode  Island  (1874-1892).  Even  in  these,  however,  as  also  in  the 
standard  tables  published  by  certain  states,  errors  occur,  so  that  at 
present  it  is  necessary  to  go  back  to  the  original  annual  reports  of 
each  state  for  assurance  of  correctness;  and  very  possibly  in  so  doing 
one  will  be  confronted  by  differing  statements  of  total  deaths  or  other 
items  in  various  tables  of  the  same  report,  or  perhaps  find  that  the 
method  of  treating  stillbirths  changed  from  year  to  year,  so  that  it  is 
absolutely  impossible  to  know  in  a  given  instance  whether  they  were 
or  were  not  included  in  the  total  number  of  births  or  deaths. 

Such  standard  tables  are  equally  necessary  for  cities,  as  shown  by 
the  valuable  series  published  by  Mr.  Hoffman1  and  the  summaries 
prepared  by  Doctor  Chapin  for  the  city  of  Providence.2  In  the  latter 
case  it  was  necessary  to  go  back  to  the  original  returns  and  ascertain 
the  true  number  of  stillbirths  ("  dead  at  birth"),  so  that  the  figures  for 
total  living  births  and  total  deaths  (exclusive  of  stillbirths)  might  be 
comparable.  The  method  of  compiling  deaths  of  children  who  had 
lived  less  than  a  week  after  birth  as  stillbirths  had  been  followed  up 
to  1889,  contrary  to  the  present  practice  of  the  office.  Standard  tables 
for  individual  causes  of  death  are  especially  important,  but  present 
great  difficulties  owing  to  the  changes  in  methods  of  classification.  The 
work  can  best  be  done  by  those  having  access  to  the  original  returns 
and  familiar  with  office  rules. 

UNIFORM   MODE    OF    STATEMENT    OF    CAUSE    OF    DEATH    INDISPENSABLE. 

Identical  schedules  are  necessary  to  secure  comparable  results  in 
statistics.  One  of  the  most  important  statements  made  upon  the 
certificate  of  death — perhaps  the  most  important  for  the  uses  of  the 
data  for  sanitary  purposes — is  the  statement  of  cause  of  death.  In 
deaths  from  disease  this  statement  is  usually  made  by  the  attending 
physician,  and  in  deaths  of  sudden  occurrence,  under  suspicious  cir- 
cumstances, or  from  violence,  by  the  coroner  or  medical  examiner.  In 
order  to  obtain  a  definite  and  satisfactory  statement  for  statistical 
purposes,  the  physician  or  coroner  should  clearly  understand  just 

1  The  General  Death  Rate  of  Large  American  Cities,  1871-1904,  by  Frederick  L.  Hoffman.    Publica- 
tions of  the  American  Statistical  Association,  March,  1906. 

2  Fifty-first  Annual  Report  upon  the  Births,  Marriages,  and  Deaths  in  the  City  of  Providence  for  the 
year  1905,  including  Tables  for  Fifty  Years.    By  Charles  V.  Chapin,  M.  D.,  city  registrar. 


10 

what  kind  of  information  is  desired,  and  how  the  cause  or  causes  of 
death  should  be  stated  so  that  the  mortality  statistics  can  be  correctly 
compiled.  If  a  sequence  or  certain  order  of  statement  of  the  causes 
of  death,  such  as  "primary,"  "secondary,"  etc.,  be  necessary,  it  should 
be  plainly  and  unmistakably  provided  for  on  the  blank,  and  the  exact 
meaning  and  relation  of  the  qualifying  terms  should  be  understood  by 
all  concerned. 

From  the  point  of  view  of  the  Bureau  of  the  Census  this  is  especially 
important  for  two  reasons: 

1.  Ail  transcripts  of  deaths  received  from  the  states  and  cities  con- 
stituting the  registration  area  of  the  United  States  are  made  upon 
blanks  of  the  standard  form.     When  copied  from  original  certificates 
made  out  upon  other  forms  of  blanks,  or  perhaps  upon   materially 
altered  standard  blanks,  the  character  of  the  returns  may  be  consider- 
ably changed  and  quite  different  relations  be  shown  for  the  causes 
reported  than  those  originally  indicated  by  the  physicians  or  coroners. 

2.  It  is  quite  impossible  for  the  Bureau  of  the  Census  to  cooperate 
with  state  and  city  offices  in  instructing  physicians  and  coroners  as  to 
how  they  shall  return  causes  of  death  so  as  to  be  most  serviceable  for 
the  compilation  of  mortality  statistics  unless  the  blanks  in  use  contain 
a  uniform  method  of  statement. 

MODIFICATION    OF    THE    STANDARD    BLANK    PROPOSED. 

While  the  standard  certificate  of  death  has  proved  very  satisfactory 
in  practical  use  during  the  time  since  its  adoption,  it  has  not  proved 
to  be  wholly  free  from  uncertainty,  as  understood  by  physicians.  It 
also  possesses  the  fault,  in  common  with  every  other  blank  used  in  this 
countr}7  and  many  of  those  used  abroad,  that  it  does  not  properly  pro- 
vide for  the  statement  of  causes  of  death  due  to  violence.  Primarily 
prepared  for  the  return  of  deaths  from  disease,  the  form  does  not 
suggest  the  statement  of  the  most  essential  particular  required  for  the 
classification  of  deaths  from  violent  causes,  namely,  whether  the  means 
of  death  was  of  an  accidental,  suicidal,  or  homicidal  character.  An 
explicit  statement  in  this  respect  is  contained  in  the  form  proposed, 
where  every  physician  or  coroner  can  read  it  while  filling  out  the  cer- 
tificate of  death,  and  if  generally  adopted  a  marked  improvement 
should  result  in  the  precision  of  this  very  important  class  of  statistics. 

The  new  form  is  presented  for  the  criticism  of  all  interested,  and 
with  the  express  request  that  it  be  not  adopted  by  any  local  office, 
except  in  a  merely  experimental  way,  until  it  has  been  thoroughly 
considered,  reported  upon  through  the  proper  channels,  and  officially 
recommended  by  the  organized  registration  officials  of  the  United 
States.  Upon  the  possibility  of  deliberate  action  upon  such  a  question 
as  this,  followed  by  actual  compliance  with  the  decisions  made,  depends 
the  outlook  for  improvement  in  American  vital  statistics.  Unless  reg- 
istration officials  can  agree  upon  the  adoption  of  some  uniform  methods, 


11 

and  then  let  them  stay  adopted  and  in  force  until  regularly  and  con- 
sistently modified  by  general  agreement,  it  is  quite  impossible  to  expect 
a  homogeneous  bod}^  of  national  statistics.  Without  such  agreement 
in  practice  the  form  proposed  would  only  add  one  more  to  the  already 
too  numerous  list,  and  would  demonstrate  that  it  is  quite  impossible 
to  build  a  uniform  and  effective  statistical  administration  upon  the 
sand  of  shifting  individual  preferences. 

PERSONNEL    OF    AMERICAN    REGISTRATION    SERVICE. 

Whatever  success  is  reached  will  be  due  to  the  intelligent  action  of 
American  registrars  of  vital  statistics.  Without  organization  nothing 
can  be  accomplished,  and  the  coming  together  of  state  and  municipal 
officials  for  the  express  purpose  of  forming  a  national  association  de- 
voted to  the  improvement  of  registration  methods  and  results  is  full 
of  promise  for  better  things.  Much  is  accomplished  by  personal 
acquaintance,  and  by  the  knowledge  that  fellow-workers  in  different 
parts  of  the  country  are  watching  one's  progress.  Every  health  officer 
who  brings  the  sanitary  condition  of  his  city  to  the  attention  of  the 
people  by  means  of  reports  or  bulletins  containing  causes  of  deaths  is 
helping,  or  hindering,  the  progress  of  American  vital  statistics.  It 
has  seemed  desirable  to  list  the  state  and  city  registration  officials,1  in- 
cluding all  places  having  a  population  of  8,000  or  over  at  the  time  of 
the  last  Federal  Census,  and  also  to  show,  as  far  as  the  information  is 
available,  some  particulars  in  regard  to  whether  they  are  acting  under 
state  laws  or  city  ordinances,  or  both,  and  also  as  to  the  issue  of 
reports  and  bulletins  containing  vital  statistics. 

EXTENSION    OF    THE    REGISTRATION    AREA. 

The  extension  of  the  registration  area  by  the  inclusion  of  new 
registration  states  is  proceeding  apace.  There  were  ten  registration 
states  in  1900— Connecticut,  Indiana,  Maine,  Massachusetts,  Michigan, 
New  Hampshire,  New  Jersey,  New  York,  Rhode  Island,  and  Vermont— 
besides  the  District  of  Columbia  (city  of  Washington).  Of  these, 
two — Maine  and  Michigan — were  added  during  the  previous  decade, 
while  Delaware  was  dropped.  In  1906  five  additional  states  were 
included— California,  Colorado,  Maryland,  Pennsylvania,  and  South 
Dakota.  Complete  laws  were  enacted  in  1907  which  should  bring 
Minnesota,  Montana,  North  Dakota,  Wisconsin,  and  perhaps  other 
states,  into  the  list.  Earnest  efforts  will  be  made  by  the  state  authori- 
ties in  Kentucky,  Ohio,  and  Virginia  to  secure  adequate  legislation 
in  1908,  and  Illinois,  Kansas,  and  other  states  will  endeavor  to  secure 
it  in  1909.  But  since  1900  no  registration  cities  in  nonregistration 
states  have  been  added,  although  it  is  entirely  practicable  for  many 
cities  in  states  which  are  not  likely  to  secure  effective  state  registra- 
tion for  some  years  to  come  to  pass  at  once  local  ordinances  for  this 

1  See  Appendix  B. 


12 

purpose,  and  so  execute  them  as  to  obtain  complete  registration  of 
deaths.  As  soon  as  this  is  done  and  the  results  tested,  the  cities  can 
at  once  be  admitted  into  the  registration  area.  The  attention  of  city 
authorities  whose  cities  are  not  included  in  the  list  of  cities  having 
effective  registration 1  is  called  to  this  fact,  and  suitable  action  is  sug- 
gested, provided  that  the  cities  are  free  to  act  independently  unham- 
pered by  defective  state  laws.  It  would  be  well  also  if  state  boards 
of  health  in  nonregistration  states  in  which  the  prospect  of  the* enact- 
ment of  a  general  state  law  seems  remote  would  at  once  use  their 
influence  to  promote  municipal  registration  under  uniform  local  ordi- 
nances and  by  means  of  the  standard  blanks  containing  all  of  the 
essential  statistical  items. 

It  is,  indeed,  not  necessary  to  wait  until  the  limit  of  8,000  population 
is  reached,  although  this  governs  the  admission  of  separate  registra- 
tion cities.  For  local  sanitary  uses  and  for  legal,  historical,  and 
genealogical  purposes',  registration  ma}r  yield  excellent  results  in  much 
smaller  places.  Every  American  citizen  should  take  pride  in  having 
his  personal  and  family  history  properly  recorded,  and  in  future  years 
the  official  registers  of  births  and  deaths  will  be  regarded  as  an  invalu- 
able possession.  As  an  example,  the  city  of  Keene,  N.  H.,  not  long 
ago  published  a  volume2  containing  the  early  records  of  births  (1742- 
1877),  marriages  (1753-1854),  and  deaths  (1742-1881),  concerning  which 
it  is  said:  "These  records  are  of  invaluable  service  to  historians  and 
genealogists  and  ought  never  to  be  allowed  to  perish.  Once  in  print 
the  record  of  these  facts  will  be  indestructible.  After  the  publica- 
tion of  the  vital  statistics  it  would  be  comparatively  safe  to  send  all 
the  old  and  badly  worn  town  records  to  be  cleansed,  rebound  and 
covered,  page  by  page,  with  overlays  of  transparent  silk,  as  is  done  in 
such  cases,  thus  permanently  preserving  the  old  volumes.1'  The  first 
state  law  for  the  registration  of  vital  statistics  in  New  Hampshire  was 
enacted  in  1849,  at  which  time  Keene,  although  having  only  about 
3,000  inhabitants,  had  had  local  registration  for  over  a  century.  The 
tender  care  taken  of  these  old  returns  shows  the  estimation  placed 
upon  them  by  the  descendants  of  the  men  whose  vital  statistics  are 
there  recorded,  and  reveals  the  duty  to  the  future  owed  by  the  gener- 
ation of  to-daj7. 

In  conclusion,  thanks  are  due  to  American  and  foreign  registrars 
for  samples  of  blanks  and  information  concerning  their  use,  and  sug- 
gestions and  criticisms  in  regard  to  the  conclusions  reached  will  be 
warmly  welcomed  both  from  registration  officials  and  experts  and  from 
physicians  and  coroners,  upon  whose  statements  of  causes  of  death, 
primarily,  is  founded  the  whole  edifice  of  mortality  statistics. 

1  Appendix  B. 

2  Vital  Statistics  of  the  Town  of  Keene,  N.  H.,  compiled  from  the  Town  Records,  First  Church  and 
Family  Records,  the  Original  Fisher  Record,  and  the  Newspapers.    By  Frank  H.  Whitcomb,  City 
Clerk.    Authorized  by  vote  of  the  City  Council,  June  1, 1905. 


MODES  OF  STATEMENT  OF  CAUSE  OF  DEATH  AND 
DURATION  OF  ILLNESS  UPON  CERTIFICATES  OF 
DEATH. 

The  wording  and  arrangement  of  the  form  provided  on  the  certifi- 
cate of  death  for  the  statement  of  cause  of  death  by  the  attending 
physician  or  coroner  is  one  of  the  most  important  features  of  the 
blank.  The  information  to  be  thus  obtained  is  very  valuable,  and  the 
tables  of  causes  of  death  contain  perhaps  the  most  useful  and  charac- 
teristic data  of  mortality  statistics.  Their  value  is  largely  dependent 
upon  a  full  understanding  by  those  who  originally  report  the  causes  of 
death  of  just  what  should  be  properly  understood  l>y  that^terrn — what 
is  essential  and  what  is  not  essential  to  state  concerning  the  causes  of  a 
death.  Many  of  the  imperfections  of  mortality  statistics  at  the  present 
time  arise  from  the  fact  that  complete  statements  of  cause  of  death  in 
a  form  best  adapted  to  statistical  compilation  are  not  obtained. 

To  some  extent  this  unsatisfactory  condition  is  due  to  a  lack  of  defi- 
nite agreement  as  to  just  what  is  wanted  from  the  physician.  Physi- 
cians in  active  practice  can  not  be  expected  to  take  interest  in  the 
minutiae  of  nosological  classifications,  or  to  specif}7  the  relations  of 
several  causes  of  death  so  that  the  compiler's  task  will  be  clear  and 
easy,  unless  the  questions  addressed  to  them  are  entirely  definite  and 
unambiguous.  Apparently  slight  variations  in  framing  the  schedules 
in  this  respect  may  be  responsible  for  serious  differences  in  the  char- 
acter of  the  replies,  and  even  the  order  of  the  replies,  if  order  be 
taken  as  a  basis  of  classification,  may  affect  the  statistical  results. 

Attempts  have  been  made  to  secure  precise  information  by  the  use 
of  various  qualifying  words  or  expressions  in  the  blanks,  or  by  the 
use  of  explanatory  notes  or  instructions.  Among  the  words  com- 
monly found  modifying  the  return  of  cause  of  death  are  the  following: 
44 Primary,"  " secondary,"  u  chief,"  " determining,"  " consecutive," 
"contributory,"  "immediate,"  ""remote,"  etc.  It  is  certain  that 
some  of  these  terms  are  understood  in  very  different  senses  by  various 
physicians,  as  well  as  by  the  registration  officials  who  compile  the  cer- 
tificates of  death  in  which  they  appear. 

The  statement  or  omission  of  the  statement  of  duration  of  illness  is 
also  very  important  as  affecting  the  compilation  of  the  data.  In  Eng- 
land, according  to  the  "  Rules  as  to  Classification  of  Causes  of  Death," 

(13) 


14 

published  by  a  committee  of  The  Incorporated  Society  of  Medical 
Officers  of  Health  in  1901,  of  Which  committee  the  distinguished  vital 
statistician :  Doctor  Arthur:  Newsholme  was  chairman,  the  element  of 
duration  is  adopted  as  the  basis  of  the  first  and  most  important  general 
rulf  f oi1  ihe  compilation:  of  joitit  causes  of  death: 

With  the  following  exceptions,  the  general  rule  should  be  to  select  from  several 
diseases  mentioned  in  the  certificate  the  disease  of  the  longest  duration  [italics  in  origi- 
nal]. In  the  event  of  no  duration  being  specified,  the  disease  standing  first  in  order 
should  be  assumed  to  be  the  disease  of  longest  duration. 

On  the  other  hand,  general  European  practice,  as  shown  by  the 
rules  published  by  the  Imperial  Board  of  Health  of  German}T  (1905), 
and  by  Doctor  Bertillon  (Paris  classification,  1890,  1898;  International 
classification,  1900,  1903),  lays  little  direct  stress  upon  the  element  of 
duration  in  regulating  the  preference  of  causes  jointly  returned,  and 
the  certificates  of  death  in  use  do  not  usually  contain  this  item  of 
information.  In  the  United  States  practice  is  unsettled.  So  far  as 
the  rules  for  jointly  returned  causes  published  in  connection  with  the 
International  classification  have  been  followed  it  is  probable  that 
the  duration  of  illness  has  been  ignored.  Many  registrars,  however, 
decide  as  to  the  "acute"  or  "chronic"  character  of  certain  diseases 
by  the  duration  stated,  or,  in  the  absence  of  a  statement  of  duration, 
by  the  period  of  medical  attendance.  In  the  Mortality  Statistics  of 
the  Seventh  Census  of  the  United  States,  1850,  may  be  found  tables 
showing  the  "  Duration  of  sickness"  in  connection  with  the  causes  of 
death  compiled,  but  the  item  was  omitted  from  the  mortality  sched- 
ules of  subsequent  censuses,  and  was  not  restored  until  the  adoption  of 
the  standard  certificate.  In  the  instructions  issued  for  the  return  of 
deaths  for  the  calendar  year  1906  upon  the  standard  blanks  for  tran- 
scripts of  certificates  of  death,  it  is  requested  that  the  duration  of 
illness  be  given  in  all  cases  in  which  it  appears  upon  the  original 
returns.  It  is  desirable  that  registrars  should  endeavor  to  secure  a 
proper  statement  of  duration  of  illness  for  all  deaths  registered  with 
them. 

In  order  to  supply  a  basis  for  specific  recommendations  as  to  these 
items,  it  will  be  of  service  to  examine  the  forms  of  statement  now  in 
use  in  this  country  (samples  collected  in  July,  1906),  and  to  compare 
them  with  some  forms  used  abroad. 

UNITED    STATES. 

A.  Standard  certificate  of  death. — The  standard  certificate  of  death, 
in  the  precise  form  adopted  by  the  United  States  Bureau  of  the  Cen- 
sus as  a  result  of  cooperation  with  the  American  Public  Health  Asso- 
ciation, has  the  following  arrangement  for  the  statement  of  cause  of 
death  and  duration  of  illness: 


15 


[1]  U.  S.  Bureau  of  the  Census;  many  states  and  cities.     X  I.1 
The  CAUSE  OF  DEATH  was  as  follows: 


(DURATION)  __  --DAYS 


Contributory 


(DURATION) 


Following  is  a  list  of  states  and  a  partial  list  of  cities  using  the 
strictly  standard  form  of  certificate  of  death,  so  far  as  it  relates  to  the 
items  under  consideration: 


California 

Iowa 

Michigan 


Bellaire,  Ohio 
Buffalo,  N.  Y. 
Canton,  Ohio 
Charleston,  S.  C. 
Columbus,  Ohio 
Findlay,  Ohio 
Fort  Smith,  Ark. 


STATES. 

Nebraska 

Oregon 

Pennsylvania 

CITIES. 

Houston,  Tex. 
Lancaster,  Ohio 
Manchester,  Va. 
Memphis,  Tenn. 
Minneapolis,  Minn. 
Nashville,  Tenn. 
Newport,  Ky. 


South  Dakota 
Washington 


Newport  News,  Va. 
Portsmouth,  Ohio 
St.  Louis,  Mo. 
Shreveport,  La. 
Toledo,  Ohio 
Wichita,  Kans. 
Yonkers,  N.  Y. 


It  should  be  understood  that  cities  in  registration  states,  e.  g., 
Detroit,  Mich.,  Philadelphia,  Pa.,  and  San  Francisco.  Cal.,  use  the 
standard  form  prescribed  by  the  state  authorities,  and  that  the  cities 
listed  above  are  chiefly  registration  cities  in  nonregistration  states. 
Two  exceptions  are  Buffalo,  N.  Y.,  and  Yonkers,  N.  Y.,  which  use 
the  exact  form  of  the  standard  certificate,  while  the  state  blank,  as 

shown  in  the  next  section  (form  [7]),  contains  a  slight  modification. 

. : «      . 

1  Indicates  that  blank  is  reproduced  in  same  size,  approximately,  as  original;  x£  indicates  reduc- 
tion to  about  one-half  size,  etc.  In  some  ca,ses  the  printer  has  not  uniformly  reduced,  but  merely 
narrowed  the  blanks,  as  in  forms  [30],  [41] fete.  In  such  cases  it  should  be  understood  that  addi- 
tional blank  space  exists  on  the  originals. 


16 

B.  Modified  standard  certificate  of  death,. —Some  of  the  variations 
that  have  already  developed  since  the  adoption  of  the  standard  certifi- 
cate in  1902  may  be  seen  in  the  following  examples: 

[2]  Colorado;  Utah.     X  1. 
The  CAUSE  OF  DEATH  was  as  follows: 

Chief  Cause  .,_*- 

Where  Contracted—  Duration  Days 

Contributory   (if  any) 

Where  Contracted .__  -Duration-  Days 

The  Colorado  blank  has  the  same  general  arrangement  as  the  Utah 
form  shown  above,  but  contains  an  additional  leader  line  for  "Chief 
Cause"  and  omits  the  word  "Days"  after  the  word  "Duration." 

The  instructions  to  physicians  on  the  back  of  the  Utah  certificate 
ask  them  to  state  the  "primary  and  contributory  causes  of  death,  with 
the  duration  of  each,"  and,  if  from  peritonitis  or  septicemia,  to  "give 
the  contributing  cause,  especially  for  females  of  child-bearing  age." 

[3]  Indiana  (1906).     X  1. 

.    .    .    the  cause  of  death  was  as  follows  : 

Chief  Cause. 

j Duration 


Immediate  Cause 


.Duration, 


Instructions:  "  Write  the  name  of  the  disease  which  caused  the  death.  If  the  patient 
had  pulmonary  tuberculosis  and  died  from  hemorrhage  of  the  lungs,  write  pulmo- 
nary tuberculosis  as  th£  disease  causing  death  and  pulmonary  hemorrhage  as  the 
immediate  cause." 


The  above  form  was  in  use  in  July,  1$06,  when  the  general  collection 
of  specimens  was  made.     At  present  a  new  form  is  in  use: 


17 

[4]  Indiana  (1907).       X  1. 
The  IMMEDIATE  CAUSE   OF  DEATH  ivas  as  follows: 


(duration) days 

Contributory . 

(duration) days 

InslJIuctions:  "Write  the  name  of  the  disease  which  caused  the  death.  If  the 
patient  had  pulmonary  tuberculosis  and  died  from  hemorrhage  of  the  lungs,  write 
pulmonary  tuberculosis  as  the  disease  causing  death  and  pulmonary  hemorrhage  as 
the  contributory  cause." 

[5]  Florida;  Middletown,  Ohio;  Wheeling,  W.  Va.     XL 

.    .    .    the  cause  of  death  was  as  t ollows : 

CAUSE  OF  DEATH. 


Duration 


The  first  appearance  of  the  standard  certificate  of  death  in  Census 
Circular  No.  71,  from  which  the  Middletown,  Ohio,  blank  shown  above 
was  derived,  was  somewhat  different  from  the  present  familiar  form. 

[6]  Massachusetts;  Leaven  worth,  Kans.     X  1. 

...    the  CAUSE  OF  DEATH  was  as  follows: 

Primary: '. 


(DURATION) DAYS  * 

Contributory:  _.;.,__. 

.. (DURATION) DAYS 

9159—07 2 


18 

The  regular  state  form  is  given  above.     Boston  does  not  use  the 
standard  blank;  see  form  [31]. 


[7]  New  York.     X  1. 
the  cause  of  death  was  as  follows: 


CHIEF  CAUSE 


(DURATION)  __.  DAYS 


CONTRIBUTORY 


(DURATION). __  DAY 


The  form  employed  by  the  State  Department  of  Health  is  shown 
above.  Albany  still  uses  the  old  New  York  state  blank  [29].  Buffalo 
and  Yonkers  employ  the  standard  form.  So  did  Greater  New  York 
until  recently,  so  far  as  cause  of  death  and  duration  are  concerned. 
Lately  the  matter  indicated  by  brackets  in  the  form  below  has  been 
stricken  out,  leaving  it  entirely  without  suggestion  as  to  mode  of 
stating  the  cause  of  death  and  with  no  provision  for  the  statement  of 

duration  of  illness. 

[8]  New  York,  N.  Y.     X  J. 

...     the  cause  of. death  was  as  follows: 


^[(Duration) Yrs....   ..  Mos Days.} 

[Contributory (Duration) Yrs Mos Days.} 

[9]   Vermont.     X  1. 

the  cause  of 
death  was  as  follows: 

CAUSE  OF  DEATH. 

[See  instructions  on  back.] 

Chief  _______  


Contributing. 


Duration 


19 

In  this  the  duration  is  given  for  only  the  "Contributing"  cause  of 
death. 

[10]  Baltimore,  Md.     X  1. 

CAUSE  OF  DEATH   (Secondary  or  Immediate). 


(DURATION) DAYS 

Contributory  (Primary) 

(DURATION)    DAYS 

This  form  is  of  interest  because  it  reverses  the  usual  order  of  state- 
ment, placing  the  secondary  or  immediate  cause  first  in  order,  and 
identifies  the  primary  with  the  contributory  cause. 

C.  Old  forms  used  by  Census. — In  Schedule  3  of  the  Seventh  Census, 
1850,  the  first  United  States  .Census  that  included  the  subject  of 
mortality,  two  of  the  eleven  items  related  to  cause  of  death: 

[11]   U.  S.  Census  (1850). 

10.  Disease  or  cause  of  death. 

11.  Number  of  days  ill. 

The  instructions  on  the  latter  item  are:  "  In  column  11  state  the  number  of  days' 
sickness.  If  of  long  duration,  insert  '  C.'  for  chronic." 

The  same  questions  were  employed  in  the  census  of  1860,  but  only 
the  first  ("Disease  or  cause  of  death")  in  the  censuses  of  1870,  1880, 
is'.M),  and  1900.  The  instructions  to  enumerators  of  the  censuses  of 
1880,  1890,  and  1900  were  practically  identical: 

[12.]  U.  S.  Censuses  (1880,  1890,  1900). 

The  most  important  point  in  this  schedule  is  the  question  in  column  12  [1900] 
headed  "Disease  or  cause  of  death."  Especial  pains  must  be  taken  in  this  column 
to  make  the  answer  full  and  exact,  and'  to  this  end  attention  is  called  to  the  following 
points: 

Enter  the  name  of  the  primary  disease  in  all  cases,  and  where  the  immediate  cause 
of  death  has  been  a  complication  or  consequence  of  the  primary  disease,  enter  that 
also.  For  instance,  enter  all  cases  of  death  resulting  either  immediately  or  remotely 
from  measles,  scarlet  fever,  typhoid  fever,  remittent  fever,  smallpox,  etc.,  under  the  names 
of  those  diseases,  but  add  also  dropsy,  hemorrhage  from  the  bowels,  pneumonia,  etc.,  if 
these  occurred  as  complications  and  were  the  most  immediate  cause  of  death. 
»*  #»»»'•* 

Distinguish  between  acute  and  chronic  bronchitis,  acute  and  chronic  dysentery 
or  diarrhea,  acute  and  chronic  rheumatism. 


20 

In  1880  and  1890,  in  addition  to  the  deaths  returned  upon  the  regu- 
lar schedules,  an  effort  was  made  to  collect  voluntary  returns  from 
physicians,  for  which  purpose  they  were  provided  with  a  special  reg- 
ister of  deaths.  As  shown  on  page  xi,  Mortality  and  Vital  Statistics, 
Part  I,  Tenth  Census  (1880),  the  form  was  as  follows: 

[13]     U.  S.  Censuses  (1880,  1890). 
Cause  or  Causes  of  Death:f 


Was  a  post-mortem  held  ? 


Name   of  Physician: 


fUnder  "cause  or  causes  of  death"  insert  remote,  immediate,  and  concur- 
ring causes.  For  instance,  insert  " measles  and  pneumonia,"  or  "difficult 
labor,  peritonitis,  and  septicemia,"  or  "scarjet  fever,  nephritis,  dropsy,  and 
coma,"  in  cases  representing  these  phenomena. 

as=If  the  true  cause  of  death  is  not  certainly  known,  insert  names  of  symp- 
toms with  across,  thus:  "Convulsions  and  coma  x;  paralysis  of  the  heart, 
x,"  etc. 

In  the  introductory  remarks  of  the  Report  on  Vital  and  Social  Sta- 
tistics of  the  Eleventh  Census  (1890),  Part  I,  page  8,  may  be  found  a 
form  recommended,  after  study  of  the  various  types  at  that  time  in 
use,  in  which  the  sole  question  is  as  follows: 

[14]     II.  S.  Census  (1890). 
Disease,  or  cause  of  death,  __ 


Subsequently,  in  connection  with  the  preparations  for  the  Twelfth 
Census  (1900),  the  following  form  was  recommended,  and  may  still  be 
found  in  use  to  some  extent: 

[15]     U.  S.  Census  (1899);  Minnesota1;  various  cities.     X  2- 
12.  Disease  or  Cause  of  Death:  DURATION. 

CHIEF  CAUSE 

CONTRIBUTING  CAUSE .__ 


PLACE  WHERE  DISEASE  WAS  CONTRACTED,  if  other  than  place  of  death: 


1  Under  old  law;  superseded  by  act  of  1907. 


21 
This  blank  was  in  use  in  1906  in  the  following  cities: 

Akron,  Ohio  Hamilton,  Ohio  Paducah,  Ky. 

Columbus,  Ga.  Ironton,  Ohio  Salem,  Ohio 

Dayton,  Ohio  Kansas  City,  Mo.  Springfield,  Ohio 

East  Liverpool,  Ohio  Lincoln,  Nebr.  Tiffin,  Ohio 

Fort  Worth,  Tex.  Louisville,  Ky.  Youngstown,  Ohio 

Fremont,  Ohio  Lynchburg,  Va.  Zanesville,  Ohio 

Greenville,  Ohio  Marion,  Ohio 

Also,  similar  in  general  arrangement,  but  with  different  wording, 
are: 

[16]     Washington,  D.  C.     X  £. 

DURATION 
13.  Cause  of  Death 

PRIMARY 

IMMEDIATE 

[17]     Atlanta,  Ga.;  Augusta,  Ga.     X  i 

Duration 

12.  DISEASE  OR  CAUSE  OF  DEATH. 
Immediate  Cause 
Primary  or  Contributing  Cause  ._ 


D.  Miscellaneous  forms. — Despite  the  efforts  at  uniformity  shown  in 
the  preceding  groups  of  blanks,  there  is  still  a  considerable  variety  of 
forms  in  use  in  the  United  States,  most  of  which  are  employed  only  in 
the  states  or  cities  in  which  they  have  originated.  The  following  state 
forms  give  both  a  differential  statement  with  reference  to  cause  and  a 
statement  of  duration:  Connecticut,  Illinois,  Kansas,  Maryland,  New 
Hampshire,  Texas,  and  Wisconsin.  Alabama  and  Maine  make  no  dis- 
tinction on  this  point  and  do  not  provide  for  duration.  The  Rhode 
Island  blank  suggests  a  statement  of  causes  of  death  "in  order  of 
occurrence,"  but  offers  no  prescribed  form  of  statement,  while  the 
New  Jersey  form  asks  for  only  a  single  cause,  but  requires  statement  of 
duration.  In  Alabama,  Illinois,  Kansas,  Maryland,  Texas,  and  Wis- 
consin,.all  of  which  states  with  the  exception  of  Maryland  are  part  of 
the  nonregistration  area,  the  state  forms  are  not  used  exclusively,  but 
certain  cities— e.  g.,  Mobile,  Ala.,  Chicago,  111.,  Topeka,  Kans.,  Balti- 
more, Md.,  Galveston,  Tex.,  and  Milwaukee,  Wis. — prepare  their  own 
forms. 

STATES. 

Following  are  the  state  forms  of  this  group: 

[18]   Alabama.      X  1. 
Cause  of  death  . . 


22 

[19]  Connecticut. 


X 


2.   Primary  cause  of  death 3.   Duration  of  disease days 

4.  Secondary  or  contributory 5.   Duration  of  days 


[20]  Illinois.     X  |. 


CAUSE  OF   DEATH 


Immediate  Cause 


Contributory  Cause  or  Complication- 


Duration 


Years     Months     Days      Hours 


Instructions:  "In  the  settlement  of  life  insurance  and  for  many  other  purposes  the 
duration  of  the  immediate  proximate  or  chief  and  determining  cause  of  death  is 
required  to  be  stated,  as  also  the  character  and  duration  of  contributory  causes  or 
complications." 

[21]   Kansas.     X   1. 

7.  Cause  of  death 

8.  Occupation 

9.  Nationality 

10.  Place  of   death  ___ 

11.  Duration  of  disease 

12.  Complication 

13.  Duration  of  complication  __ 

[22]  Maine.     X   1. 
Cause  of  Death, 


[23]  Maryland.     X  §. 


CAUSES  OF  DEATH 


Primary 


Immediate 


How  long 


How  long 


1  Various  sizes  are  used  in  different  counties. 


23 

[21]     New  Hampshire.     X  1. 


Cause  of  Death, 

_, Duration, 

Contributing  Cause, 

Duration, 


[25]     New  Jersey.     X  £. 


the  cause  of  death  was_ 

..._. 

_ Length  of  sickness ___ 


[26]     Rhode  Island.     X  i 


Please  state  different  causes  of  death  in  order  of  occurrence  as  FULLY  as  possible,  particularly  in 
DOUBTFUL  cases. 


Date  of  Death-.  -190        Hour M. 

Name 

Causes  of  Death 


As  an  addition  to  the  regular  form,  the  blank  used  in  the  city  of 
Providence  has  a  line  for  the  ''Duration  of  Diseases,"  and  also  the 
following  special  request  to  the  reporting  physician: 


TOTU  p     DU  VQ|P|  AM         If  more  than  one  cause  of  death  is  given  please 
ill-     l          IOIWIAAIN.  that  which  you  consider  the  most  important. 


underline 


24 


Concerning  this  request  Doctor  Chapin  writes  (August  8,  1907): 
"I  am  sorry  to  say  that  it  is  only  occasionally  that  our  physicians 
underline  the  cause  of  death  which  they  consider  the  most  important. 
Sometimes  when  they  do  so  indicate  a  cause  it  is  evident  that  they 
mistake  my  intention,  for  the}^  sometimes  indicate  the  immediate, 
rather  than  the  most  important  cause  of  death;  yet  in  the  aggregate 
during  the  year  there  are  quite  a  number  of  certificates  brought  in  on 
which  this  indication  by  the  physician  of  the  proper  cause  for  tabula- 
tion is  of  value.  I  shall  probably  continue  to  make  the  request,  as 
heretofore.  " 

[27]  Texas.     X  \. 


CAUSE  OF  DEATH 

DUR> 

\TION 

Immediate  Cause 

YEARS 

MONTHS 

DAYS 

HOURS 

Contributory  Cause  

20.    Cause  of  death 


.  Duration  of  disease 


[28]   Wisconsin.     X  J. 
Primary  

Secondary 


The  standard  certificate  is  required  by  the  new  registration  law  of 
190T. 

CITIES. 

Among  the  cities  of  this  group  making  provision  on  their  certifi- 
cates for  a  compound  statement  of  cause  and  also  for  duration  are: 
Albany,  N.  Y. ;  Boston,  Mass.;  Chicago,  111.;  Chillicothe,  Ohio;  Cin- 
cinnati, Ohio;  Cleveland,  Ohio;  Fredericksburg,  Va. ;  Galveston, 
Tex.;  Milwaukee,  Wis.;  and  Topeka,  Kans.  Some  give  only  a  simple 
statement  of  cause  and  no  statement  of  duration:  Alliance,  Ohio; 
Americus,  Ga. ;  Bessemer,  Ala.;  Biloxi,  Miss.;  Chattanooga,  Tenn. ; 
Greensboro,  N.  C. ;  Jacksonville,  Fla. ;  Key  West,  Fla. ;  Lexington, 
Ky. ;  Martinsburg,  W.  Va. ;  Newbern,  N.  C. ;  New  Orleans,  La.;  and 
Parkersburg,  W.  Va.  Others  give  a  single  cause,  with  duration,  as 
Defiance,  Ohio;  Mobile,  Ala.;  St.  Paul,  Minn.;  and  others  give  a 
double  statement  of  cause,  with  no  duration,  as  Cheyenne,  Wyo.; 
Knoxville,  Tenn. ;  and  St.  Joseph,  Mo. 


25 

Some  of  the  forms  follow: 

[29]   Albany,  N.  Y.     X  *. 
.    .    .    the  Cause  of  h death  was  as  hereunder  written: 


Chief  and        1 
Determining    J 


( Consecutive,  and 


( 'attributing 


i 


Duration  of  Disease  in  Years, 
Months,  Days  or  Hours,  f 


a  . 


ill 


8  c  a 
5  s?  s 

•0.5  S 

o>  bcS 

£«a 

^  fl 


. 

Sanitary  observations,  __ 


ThisJs  the  old  and  original  form  of  the  New  York  state  blank, 
which  is  shown  on  page  111  of  the  Third  Annual  Report  of  the  State 
Board  of  Health  (1883). 

[30]  Boise,  Idaho;  Covington,  Ky.;  and  other  cities.     X  £• 

Remote  or  Predisposing 


18. — Cause  of  death, 

( Immediate 

19. — Duration  of  last  illness  _. 


The  following  cities  employ  this  form,  in  some  cases  without  state- 
ment of  duration: 

Boise,  Idaho,  Chillicothe,  Ohio,  Sidney,  Ohio, 

Bucyrus,  Ohio,  Covington,  Ky.,  Troy,  Ohio. 

Cambridge,  Ohio,  Elyria,  Ohio, 

Canal  Dover,  Ohio,  Fostoria,  Ohio, 

[31]  Boston,  Mass.     X  J. 
(  Chief  cause, 

Disease  \ 

[  Contributing  cause, 


(  Chief  Causey-- 
Duration < 

{  Contributing  cause, 


26 

[32]    Chicago,  111.     Xj. 


CAUSE  OR  CAUSES  OF  DEATH. 
Immediate  and    Determining                                       -\ 

DURATION  OF  CAITSES. 

Years. 

Months. 

Days. 

Hours. 

.__•___                          [ 

) 
Contributing  Cause  or  Complication                         ^ 

„        *...    .         .                                 \ 

On  the  reverse  side:  "In  the  settlement  of  life  insurance  and  for  many  other  pur- 
poses the  duration  of  the  proximate  or  immediate  and  determining  cause  of  death  is 
required  to  be  stated,  as  also  the  character  and  duration  of  contributing  cause  or  com- 
plication. Albuminuria,  emphysema,  jaundice,  or  dropsy — the  primary 
cause  should  be  given." 

[33]     Cincinnati,  Ohio;  Norwalk,  Ohio.     X$. 


the  cause  of  death  was  as  hereunder 
written: 
Disease  Causing  Death*- .  - 

Immediate  Cause  of  Death _"_. 

Contributory  Causes  or  Complications,  ifany.__ 


DURATION  OK  EACH  CAUSE. 


/  Place  where  Disease  causing  Death  was 
\  contracted,  if  other  than  place  of  Death. 


*In  case  of  a  Violent  Death,  state  (1)  mode  of  injury,  and  whether  accidental,  suicidal  or  homi- 
cidal; (2)  what  was  the  nature  of  the  injury  and  the  immediate  cause. of  death;  (3)  contributory 
causes  or  conditions,  e.  g.,  septicemia.  Also,  whether  operation  was  performed,  etc. 

In  deaths  from  tuberculosis,  cancer,  etc.,  always  specify  what  organ  or  part  of  the  body  was  affected. 
In  septicemia,  give  cause,  especially  puerperal. 

This  form  is  identical  with  the  original  Michigan  blank  (1897), 
except  that  it  is  of  greater  size.  Milwaukee,  Wis.,  also  uses  the  same 
form  of  statement  as  regards  cause,  except  that  the  item  relative  to 
post-mortem  is  omitted. 

[34]     Cleveland,  Ohio.     Xi 

(  Chief  __  __. Duration Days, 


Cause  of  Death: 


Contributing.,  ..Duration __.  _.Days. 


[35]  Galveston,  Tex.     X  \. 
Disease,  Injury  or  other  Efficient  and  Remote  Cause  of  Death 


Disease,  Injury  or  other  Efficient  and  Immediate  Cause  of  Death 


27 


[36]  Knoxville,  Term.     X 1. 

Cause  of  Death,  .. 

Give  immediate  cause  of  Death. 

Name  of  Disease,... 

Give  remote  cause  of  Death. 

If  Stillborn,  state 

Supposed  Cause  of  Death,  

p 
[37]  Macon,  Ga.     X  1. 

CAUSE  OF  DEATH. 
Immediate 

Contributing 

Remote .._ 

[3gJ  Massillon,  Ohio.     X  £. 

f  Chief  or  Primary . 

Cause  of  Death :  \ 

I  Contributory  or  Immediate.... 

[39]  Spartanburg,  S.  C.     X  £. 

...     the 
Cause  of death  was: 

First  (Primary), „ ... 

Second  (Immediate), __. 

[40]  Topeka,  Kans.     X  1. 
Cause  of  Death, 
Contributing  Cause,  Duration. 

[41]  Worcester,  Mass.     X  i 

Disease        p.^   ^   primary>  Duration  of 

Cause 

Death.      Secondary,      .     ,      Duration  of 


28 

FOREIGN    COUNTRIES. 

1.  France. — Heretofore  individual  returns  have  not  been  made  to 
the  central  statistical  office  of  France,  numerical  statements  having 
been  prepared  by  the  communal  administrations,  these  totalized  by 
prefectures  for  each  department,  and  the  department  totals  transmitted 
to  the  office  of  the  Statistique  generate  de  la  France.  Beginning  Jan- 
uary 1,  1907,  however,  this  system  has  been  changed,  and  colored  slips 
representing  individual  living  births  (rose),  deaths  (green),  stillbirths 
(chamois),  marriages  (blue),  divorces  (yellow),  legitimations  (orange), 
transcriptions  or  corrections  (violet),  together  with  a  bordereau,  or 
statement  slip  of  transmission  (white),  giving  the  first  and  last  reg- 
istered numbers  and  the.total  number  of  each  class,  are  sent  in  on  the 
eighth  days  of  January  and  July  for  the  preceding  half  years.  The 
system  is  much  like  that  employed  in  many  states,  and  recommended 
by  the  Bureau  of  the  Census,  for  the  monthly  transmission  of  returns. 
As  France  possesses  a  deserved  reputation  for  perfection  in  statistical 
detail,  it  will  be  of  interest  to  present  a  reduced  facsimile  of  the  Bul- 
letin de  Deces  (the  reference  imprint  thereon  gives  exact  details  of  the 
color,  size,  and  weight  of  paper),  together  with  a  translation  of  the 
question  concerning  cause  of  death. 


29 

[42]     France.      X  §. 
DEPARTEMENT  REPUBLIQUE   FRANCE-USE.  ANNEE1<3__ 


ARRONIMSSKMKNT 


BULLETIN    DE    DEGES, 


X°  de  Pacte: 


Commune 


"°  d'ordre  du  de*ces: 


r's  xnnrnn  le        __  du  mois  d  „  __  19 a  ._     _.  heims  <ln 


(matin  ou  soir.) 


1.  Sexe:  masculin f£minin 

/n'indiquer  les  mois  d'age  que  pour\ 

2.  Date  etlieul  Ne  le  __       -  du  mois  d ^-19 \    les  enfants  ayant  moins  de5  ans.    / 

de         \ 
naissance.  J  a  ,.  departement  d  „ 

S'il  s'agit  d'un  a<lnltc:  gil  s'aytt  d   ,  i  ,-fant  de  mains  de  cinq  ans: 

C£libataire 
Marie        ..      Depui.s  ^gitinfe? ... 

3.  Etat  civil.    ^  cnmbien 

Veuf Tan 

Divorc6__.         n6es?  premier  n«. 

Age  au  mariage  

Si  F enfant  a  moms  d'un  an: 

4.  Si  le  Nombred'enfantsvivantsoumorts 

<f.  decede  issus  du  mariage  (morts-n6s  non  ,  ^u  gejn 

etait  compris) Mode 

*>arie.         Xombre  d.enfants  survivants  __          d'alimen-    Au  biberon  _ 
ti  tation. 

»«  Age  de  1'^poux  survivant I  Par  allaitement  mixte 

'-j. 

"Z      5.  Profession  du  decede  (!).__  -_Patron(2) Employ6(2) Ouvrier (2).._ 

2 

Professiondel'6poux  survivant  I1) Patron  (2) Employe^2) Ouvrier(2) 

S 

£      6.  Si  le  decede  est  un  enfant: 

Profession  dupere(') ___._    Patron  (2) Employt>(-') Ouv*er(2) 

Profession  de  la  mere  (') „  Patronne(-) Employee  (-) Ouvriere(2)  

^  [niguO* 

::      7.  Maladie  ou  accident  cause  de  mort    < 

( cbronique 

-jj"      8.  Le  decesa-t-il  ete  constate  par  un  medecin? 

9 

>  , 

I  :: ,  le . 19^. 

Lf  Maire  Vu: 

S1          Le  Declant nl,  ou  le  Preposc  de  Vetat  civil,  Le  Medecin  de  I'clat  civil, 

£ 

9 

s 

g    — , 

7  (M  Preciser  le  plus  possible  la  profession. 

(2)  Oui  ou  non. 

[Translation  of  question  7.] 

(  acute 
7.  Disease  or  accident  cause  of  death 

I  chronic  _. 


30 

2.    Germany. — The  following  form  is  in  use  in  Germany: 
[43]  Germany,     x  1. 

-   C.  190         (         Hicrtcljal)r). 


id)  ber  Xotgeborenen). 
„  ,,J... ,ft  r  c  i  o  : 

(Stabtgemeinbe 
Sanbgemeinbe 
®ut8bc$irf ._ 


1.  Glummer  im  Sterbtrtgifltr:  _ 

2.  sHor=  unb  3inuinic  ( 
bco  iscrftorbcncn:   | 

obcr  ob  rotgcborcn  obcr  unbcnannt  bcrftorbcn  ? 

3.  ©efd)lcd)t:  mannlid)  obcr  tociblid)? 

4.  3eit  bco  SterbcfaUft?   SKonat: . .  lafl: ... 

Stunbc:  J.         Sonnittagft,  9tad)mittag8. 

5.  ©eburtfijaljr  unb  5ag  bc6  SJcrftorbcnen :  .. 

6.  ^amilienftanb  bco  iBcrftorbenen : 

a)  bci  ^otgcb.  u.  .Vtinbcrn  unter  1  ^al)rc:  eyelid)  cbcr  uncbclid)  gcboren? 

b)  bci  alien  iibrigcn  ^icrfoiicn:  Icbig,  t>crf)ciratctf  bcrtpit^ct,  gc[d)icbcn? 
bet  SSer^eirateten:  Waiter  ber  biircf)  biefen  Xobesfafl  gefoften  @^e: 
3a^e. 

7.  9lcligionr»bcfcnntni0: 

bci  3:otgcborencn  be§  Satcro:  „  .,.,  ber  SKuttcr:  - 

8.  a)  (Stanb,  .^aiiptbcruf,  O^ciucrbc: 

bci  $crfoncn  fiber  15  Satyrc  alt  bco  ^crftorbcncn  fclbft:.. 


ScnifftftcUuiifl  (ob  felbftanbtg,  ©etytlfe,  $rbettcr  uftt).) : 

bei  Sotgeborenen  nnb  nid)t  enrcrbtatigen  tobcrn  nntcr  15  3al)rcn 
bco  $atero:  . 

iDenn  baterloS:  ber  Gutter:  .. 
Senif§ftellnng  bco  Sater$  bcjtD.  ber  SJhtttcr : 
9.    lobcenrfad)e  (bet  ^Berungliicfung  5lrt  berfefben):  __ 


10.   ©cmcrfiuigcii,  \  53.  :  ob  anfgcfiuibcnc  iinbcfanntc  Vcid)c,  ob  anf  bciitfd)cn 
Sd)iffcn  aiif  Sec,   ober  ob  in  einer  ^Inftalt  bcrftorbcn? 
in  u>cld)cr 


[Translation  of  question  9.] 

9.  Cause  of  death  (Nature  of  accident): 


31 


3.  Great  Britain  and  Colonies. — The  forms  supplied  by  the  Regis- 
trars-General of  England  and  Wales  and  Ireland  are  identical  in  the 
arrangement  and  wording  of  this  part  of  the  blank: 

[44]  England  and  Wales;  Ireland.     X  i 
the  Cause  of  h death  was  as  hereunder  written. 


Cause  of  Death. 

Duration!  of  Disease  in 

Y~ni        Calendar 
\ears.      Monthg> 

Days. 

Hours. 

Primarv                       Enteric  Fever 

21 

Secondary               Broncho-  Pneumonia 

3 

•  — 

fThe  duration  of  each  form  of  Disease  or  Symptom  is  reckoned  from  its  commencement  until 
death  occurs. 

The  example  of  primary  and  secondary  causes  is  that  officially  given 
by  the  Registrar-General  of  England  and  Wales  in  the  book  of  forms 
.supplied  to  physicians. 

[45]  Scotland;  South  Australia.     X  5. 
.   .  .  the  Cause  of  Death  and  Duration  of  Disease  were  as  undernoted:— 


Primary  Disease  

Secondary  Diseases  ( if  any} 


(b) 


(<*) 


Cause  of  Death. 

Duration  of  Disease. 

Years. 

Months. 

Days. 

I             :              ' 

[46]     New  South  Wales.     X  I- 
the  cause  of  h . .    -  death  was  as  hereunder  written. 


J  Cause  of  Death. 

Duration  of  Disease 
in  Years,  Months, 
Days,  or  Hours,  f 

(a)  Primary 

(Actual) 

(b)  Secondary  _. 

(Contributing) 

•f-The  duration  of  each  form  of  Disease  or  Symptom  is  reckoned  from  its  commencement  until  death 
occurs. 

I N.  B.— If  the  Deceased  was  a  State  child,  boarded  out,  the  Children's  Protection  Act  of  1902  (sec. 
10)  requires  that  the  medical  attendant,  in  giving  the  cause  of  death,  should  also  certify  whether 
such  cause  was  accelerated  by  neglect  or  ill-treatment.  The  addition  of  neglect1'  or  "  no  neglect," 
under  the  cause  of  death,  will  comply  with  this  requirement. 


32 


[47]     New  Zealand.      X  1. 

the  cause  of  h  _      death  was,  _ 


Time  from 

Cause  of  Death.                         attack  till 

Death. 

- 

f 

First 


Second 

f  Each  form  of  disease,  or  symptom,  is  reckoned  from  its  commencement  till  death. 

[48]  Queensland.     X  1. 
The  cause  of  h        death  was  as  specified  at  foot  hereof. 


Cause  of  Death. 
(Disease  or  Injury.*) 

Duration  of 
Illness. 

1.  Primary 

2.  Secondary 

3.  Final 

*In  case  of  a  Death  resulting  from  fractures,  contusions,  wounds  of  any  kind,  poison,  or  drowning, 
the  Registrar-General  particularly  requests  medical  men  to  state  specifically  THE  NATURE  OF  THE 
INJURY,  and  whether  the  Cause  of  Death  was  ACCIDENTAL,  SUICIDAL,  or  HOMICIDAL. 


[49]  Tasmania.     X  }. 


Cause  of  Death — 1st 


2nd 


[50]  Victoria.     X  1. 

iJn1  cause  of  h         death  was — 


(«) 
irst: 


Second: 


Cause  of  Death. 


Duration  of 
Diseases. 


33 


•Jr.  Italy. — Individual  returns  to  the  central  bureau  of  the  government 
have  long  been  employed  in  Italy.  Unfortunately  a  copy  of  the  Italian 
blank  is  not  at  hand,  but  a  translation  of  the  reproduction  given  by 
Doctor  Bertillon  (Cows  elementaire  de  statistique  administrative,  1895, 
p.  277),  so  far  as  it  relates  to  form  of  statement  of  cause  of  death, 
with  instructions,  ma}7  be  given: 


Natural    death 


[51]  Italy.    X  1. 
Primary  disease  [Maladie  primitive']. 


Complications  of  the  disease  or  terminal  condition  [Acci- 
dent terminal'] 


[Accidental 

Violent   death1^ Suicide3  — . 
[Homicide 


'If  unable  to  certify  whether  a  death  from  violence  is  due  to  homicide,  .suicide  or  accident,  indi- 
cate the  supposed  cause. 

2  In  accidental  death  state  whether  caused  by  fall,  crushing,  burning,  drowning,  poisoning,  etc. 

3  In  suicides  indicate  the  means  employed— firearms,  cutting  instruments,  poisoning,  precipitation 
from  height,  drowning,  hanging,  crushing  under  train,  etc. 

5.  Japan. — A  reduced  facsimile  of  the  certificate  of  death  employed 
in  Japan,  and  also  a  translation  of  the  complete  instructions  issued 
to  physicians  in  connection  with  its  use,  which  were  kindly  supplied 
by  Hon.  N.  Hanabusa,  Director  of  the  Bureau  of  General  Statistics, 
Imperial  Cabinet  of  Japan,  are  given  below: 


•u 


[52]  Japan. 

i  m® 


£. 


J  g  »  » s-3  tr  j 


U  «a  IR 


m 


JRUM6H 


m 


•» 


9159—07  -  3 


34 

INSTRUCTIONS   TO   PHYSICIANS. 

The  certificate  of  death  to  be  made  by  a  physician  should  be  as  follows: 


CERTIFICATE   OF  DEATH. 

1.  Name  of  the  deceased 

2.  Sex 

3.  Date  of  birth 

4.  Occupation: 

(a)  Occupation  of  the  deceased- -- 

(b)  Occupation  of  the  head  of  household 

5.  Whether  death  by  disease,  suicide,  other  violence,  or  poison- .. 

6.  Name  of  disease,  means  of  suicide  or  kinds  of  other  violence  or  poison  -  — 

7.  Date  of  beginning  of  disease  (if  death  by  suicide,  other  violence,  etc.,  this  clause 

omitted)  -- 

8.  Date  of  death 

9.  Place  of  death 

I  certify  the  above  mentioned. 

Dated , 

Physician. 


For  1,  write  the  name  written  on  the  family  register  book.  When  the  name  is  not 
evident,  as  in  the  case  of  suicide,  other  violent  death,  etc.,  write  it  as  unknown. 

For  2,  when  the  sex  is  not  distinct  on  account  of  a  time-worn  corpse,  write  it  as 
unknown. 

For  3,  when  the  date  of  birth  is  not  evident  on  account  of  suicide,  other  violent 
death,  etc.,  write  a  conjectured  age;  and  if  it  could  not  be  conjectured,  write 
it  as  unknown. 

For  4,  when  the  deceased  is  the  head  of  household,  write  the  occupation  of  the 
deceased  only;  when  the  deceased  has  no  definite  occupation  on  account  of 
being  young,  old,  female,  etc.,  write  it  as  "has  not,"  and  write  the  occupa- 
tion of  the  head  of  the  household.  When  the  deceased  has  a  definite  occupa- 
tion and  is  not  the  head  of  household,  write  collaterally  the  occupations  of 
the  deceased  and  of  the  head  of  household.  The  nomenclature  of  occupation 
should  not  be  limited  to  the  use  of  simple  broad  terms,  as  a  "merchant"  or 
"manufacturer,"  but  be  written  in  detail  as  to  what  [kind  of  a]  merchant, 
what  [kind  of  a]  manufacturer,  etc.  When  the  occupation  is  not  certain 
on  account  of  the  case  being  suicide,  other  violent  death,  etc.,  write  it  as 
unknown. 

For  5,  write  the  distinction  of  whether  the  death  is  by  disease,  suicide,  other  violence, 
or  poison. 

For  6,  when  the  death  is  by  disease,  do  not  write  any  other  matter  than  the  name 
of  disease.  When  death  is  caused  by  two  or  more  diseases,  and  if  one  is 
primary  and  the  others  are  secondary  or  after-diseases,  write  the  primary 
disease  only.  If  each  disease  is  an  independent  one,  write  the  disease  that 
became  chiefly  the  cause  of  death.  If  the  distinction  is  found  impossible, 
write  collaterally  all  the  diseases.  When  the  disease  as  cause  of  death  can 
not  be  determined,  write  it  as  unknown.  As  for  suicide,  write  the  means  of 
it,  as,  for  instance,  by  hanging  or  strangulation,  by  drowning,  or  by  cutting 
instruments.  As  for  other  violence  and  poison,  write  the  kinds  of  them,  as, 
for  instance,  by  accidental  drowning,  crushing,  burns,  murder,  poison  of  Fugu 
(a  kind  of  tetrodon),  poison  of  alcohol,  etc. 


35 


For  7,  as  for  death  by  disease,  write  the  date  of  beginning  of  it;  if  it  is  not  evi- 
dent, write  conjectural  date,  and  if  it  is  impossible  to  conjecture,  write  it  as 
unknown. 

For  8,  no  matter  whether  the  death  is  by  disease,  suicide,  other  violence,  or  poison, 
write  the  date  of  death.  If  the  date  of  death  is  not  evident,  as  in  the  case  of 
suicide  or  other  violence,  write  conjectural  date,  prefixing  the  word  "con- 
jectural." 

6.  Sweden. — Physicians  are  supplied  with  a  copy  of  the  classifica- 
tion of  causes  of  death  and  an  alphabetical  list  of  diseases  referred  to 
the  proper  classification  number.  On  the  first  line  of  the  following 
form,  which  is  part  of  the  certificate  of  death,  there  is  to  be  written 
the  principal  cause  of  death  (hufvuddodsorsak)  and  its  classification 
Dumber,  while  the  following  lines  are  for  the  contributory  causes 
(bidragande  dodsorsaker). 

[53]  Sweden.     X  1. 


Hufvuddodsorsak:  Nomenkl.    /,.-,' 


Bidragande  dodsorsaker: 


7.  Switzerland. — The  methods  employed  by  the  Federal  Bureau  of 
Statistics  of  Switzerland  deserve  special  consideration  on  account  of  the 
great  pains  taken  to  frame  the  interrogations  as  to  cause  of  death,  the 
very  explicit  instructions,  and  the  provision  for  a  confidential  report 
by  the  attending  physician.  A  slightly  reduced  copy  of  the  blank  is 
presented  herewith,  together  with  a  translation  of  that  part  of  the 
blank  relating  to  statement  of  cause  of  death  and  including  the  sug- 
gestions to  the  physician  as  found  upon  the  reverse  side: 


36 

[54]     Switzerland.      X  §. 


Nom  du  decede: 


La  notice  pour  les  offlciers  de  1'etat  civil  se  trouve  au  verso. 


J9&=  Le  m£decin  est  pri6  de  bien  vouloir:  1°  repondre  le  plus  tot  possible  aux  questions 
8  a  10,  en  tenant  compte  des  observations  iiiscrites  au  verso,  mais  seulement 
apres  1'autopsie,  si  celle-ci  a  lieu;  2°  controler  les  reponses  donnet-s  aux  questions  1  a 
7  par  1'offieier  de  1'etat  civil  et,  cas  £ch6ant,  les  computer;  3°  apres  avoir  enlev£  le 
present  coupon,  mettre  le  bulletin  dans  1'enveloppe  ci-jointe,  fermer  cctte  derniere 
et  la  mettre  sans  retard  a  la  poste. 

Masculin. 

Arrond4  d'etat  civil:... 
Registre  des  deces  190... 


District: 


1.  Decede"  le  .' ---a---     ...  heures 

2.  Lieu  du  deces  (Commune):  -- 


(Quart.,  etc.; 
hop.,  6tabl.,  etc.)  "" 

Pour  les  non  domicilies  au  lieu  du  deces,  duree  du  s£jour: 
3.  Profession  du  decede: 

Position  dans  1'entreprise: ... 
Nature  de  1'entreprise:-- 


Si  le  d£funt  a  moins  de  15  ans,  pro-  \ 
fession  du  pere  *  ou  de  la  mere  *:  j 

4.  Etat  civil :  celibataire*  —  marie*  —  veuf  *  —  d  i  vorce*. 

P*  les  enfants  au-dessous  de  5  ans:  16git.*  —  illeg.*  —  mis  en  pension  *. 


5.  Commune  d'origine:. 

6.  Commune  de  domicile: ... 

7.  Ne  le -*— -.  1- 

8.  Declaration  me'dicale  de  la  cause  du  deces  : 

a.  Maladie   primitive    ou 

cause  primaire. 
(  En  cas  de  mort  violente,  indi- 
(fuer  le  genre  et  la  cause,  date 
deT accident,  du  suicide,  etc  ) 

b.  Maladie  consec.  et  cause 

immediate  de  la  mort 


c.  Maladies  concomit.  ou  circonst. 
dignes  d'etre  mentionnees 

9.  Autopsie:  Oui*  — Non*.- 

10.  Observations:  

(Condit.  sanit.  de  1'habitation, 
etc.— Voir  au  verso. ) 


Le  medecin  traitant* — appele  apres  la  mort*: 


* Souligner  les  mots  qui  se  rapportent  a  la  personne. 


8.  Medical  statement    of   the    cause    of   death. 

a.  Primitive  disease  or  pri-1 

inary  cause. 

(In  violent  d&titu,  state  kind  and  I 
cause,  date  of  accident,  of  sui-\    

dill     .       iff.      * 

l>.  Consecutive  disease  and  | 
immediate  cause  of} 
death. 


c.  Concomitant  or  circumstan- 
tial diseases  worthy  of  be- 
ing mentioned. 
9.  Autopsy:  Yes*  —  No.* 


10.  Observations:    - 
(Sanitary  condition  of  habita- 
tion, etc. — See  other  side. )    - 

The  physician  attending  *  —  called  after  death  * 

(Signed) ...of— 


jjgp  *  Underscore  the  words  which  apply  to  the  case. 
DIRECTIONS    FOR    USE    OF    SWISS    BLANK. 

According  to  the  directions  given  on  the  detachable  part  above  the  perforated  line, 
the  physician  is  requested  (1)  to  fill  out  questions  8  to  10,  having  regard  to  the 
"Observations  pour  le  medecin"  or  special  suggestions  printed  on  the  back  of  the 
blank,  and  waiting  until  after  the  post-mortem,  if  any  be  held,  before  entering  the 
cause  of  death;  (2)  to  check  the  replies  to  questions  1  to  7,  correcting  them  when 
necessary;  and  (3)  to  detach  the  coupon  and  mail  the  certificate,  with  statement  of 
cause  of  death,  to  the  local  registrar  (Pofficier  de  1'etat  civil)  in  a  sealed  enrelojte 
especially  supplied  for  this  purpose.  [This  is  a  "  penalty  envelope,"  which  goes 
post  free  in  the  mails;  it  bears  the  inscription  "Statistique  de  deces"  in  the  upper 
right-hand  corner  in  lieu  of  a  stamp,  and  in  the  left  corner  above,  the  words 

"Controle:  No. of  the  Register  of  Deaths,"  with  the  physician's  signature  in 

the  corner  below.  This  enables  the  local  registrar  to  identify  the  return  of  cause  of 
death  as  being  made,  without  opening  the  envelope,  which  he  is  forbidden  to  do. 
He  sends  it  intact  to  the  Federal  Bureau  of  Statistics  at  Berne  at  the  end  of  each 
month,  where  it  is  used  solely  for  statistical  purposes,  and  thus  the  confidential 
statement  of  the  physician  as  to  the  cause  of  death  is  absolutely  guarded.] 

SUGGESTIONS   TO   THE    PHYSICIAN. 

Questions.  Please  distinguish  with  care  the  primai^y  or  causal  disease  (8a)  and  the 
consecutive  or  secondary  disease  (8b). 

Question  8a  is  important  from  the  viewpoint  of  hygiene  and  sanitation,  but  it  is 
often  difficult  to  answer;  sometimes  a  reply  is  uncertain  or  impossible  to  give.  In  the 
latter  case  indicate  by  dash  after  the  question  8a,  and,  if  the  answer  is  uncertain, 
add  a  question  mark. 

In  violent  deaths  it  is  necessary  to  state  exactly  the  nature,  the  cause,  and  the  date,  and  to 
also  indicate  whether  the  death  was  due  to  suicide  (motive:  mental  disease,  alcoholism, 
etc.),  to  homicide  or  to  accident. 

It  is  generally  easier  to  reply  to  question  8b,  because  it  most  frequently  relates  to 
what  the  physician  has  been  able  to  observe  during  life  or  after  death  (autopsy? 
question  9).  There  should  be  inserted  here  the  results  of  accidents,  e.  g.,  the  nature 


38 

and  the  seat  of  the  lesions,  fractures,  dislocations,  cerebral  affections,  secondary 
inflammations,  etc. 

Question  8c.  Here  indicate  the  pathological  processes  which  accompanied  the  prin- 
cipal disease  and  which  have  influenced  its  course  and  result,  as,  for  example,  cur- 
vature of  the  spine  in  diseases  of  the  lungs  or  heart,  alcoholism  with  the  acute 
diseases,  mental  diseases,  etc. 

[The  remainder  of  the  suggestions  relate  to  sanitary  observations,  and  show  how 
the  confidential  communication  between  the  physician  and  the  central  bureau  of 
public  health  may  be  utilized  to  convey  much  information  of  value  to  the  sanitary 
service  of  the  state  not  ordinarily  obtainable  from  mortality  returns.] 

NOMENCLATURE   OF   CAUSES   OF   DEATH. 

As  an  indispensable  aid  in  securing  brief  and  precise  statements  of  cause  of  death 
Swiss  physicians  are  supplied  with  a  "  Nomenclature  of  the  Causes  of  Death,"  similar 
to  those  issued  by  the  governments  of  Sweden,  Holland,  Germany,  and  other 
countries,  and  to  the  pamphlet,  "Relation  of  Physicians . to  Mortality  Statistics," 
distributed  by  the  United  States  Bureau  of  the  Census  some  years  ago  to  every 
physician  in  the  United  States.  In  this  list  are  indicated  by  single  asterisk  (*) 
diseases  frequently  secondary,  and  by  double  asterisks  (**)  diseases  usually  or  exclu- 
sively secondary,  so  that  the  Swiss  physician  has  a  practical  guide  to  aid  him  in 
filling  out  the  form  correctly.  Here  are  some  examples: 

Acute  bronchitis  and  broncho-pneumo-      Aneurism.** 

nia.*  Meningeal  apoplexy.* 

Bronchial  asthma.*  Cerebral  hemorrhage.* 

Putrid  bronchitis.**  Abscess  of  brain.** 

Gangrene  of  lungs.**  Convulsions.** 

Pleurisy.*  Acute  parenchymatous  nephritis.* 

Empyema.**  Acute  nephritis  of  pregnancy. 

Acute  pericarditis:  Chronic  parenchymatous  nephritis.* 

a.  Simple.*  Chronic  interstitial  nephritis.* 

6.  Purulent.**  Suppurative  nephritis.** 

Endocarditis.*  Etc. 

Acquired  valvular  disease.** 

CORRECTION    OF    UNSATISFACTORY    STATEMENT    OF   CAUSE    OF    DEATH. 

Not  only  is  there  a  very  precise  blank  provided  for  the  statement  of  cause  of  death 
by  the  Swiss  physician,  together  with  explicit  instructions,  a  detailed  nomenclature 
showing  the  relations  of  individual  diseases,  and  a  system  of  post-free  confidential 
communication  assured  against  violations  of  secrecy  and  professional  confidence,  but 
the  central  office  also  carries  out  a  " follow-up  system,"  which  assures  that  the  occa- 
sional cases  of  ignorance  or  neglect  of  the  proper  form  of  statement  are  promptly 
corrected.  Here  is  the  form: 

FEDERAL  BUREAU  OF  STATISTICS, 
Berne,  ,  190 

Dr. 


DEAR  DOCTOR:  You  have  delivered  a  certificate  of  death  for  a  person  of  male 
female  sex,  occupation  __,born  ___,  died  __ , 

at  _.  .„,  St.  _.  ...,  No.  ._  ._.,  from: 


^in^ 

ff     //A,. 

39 


The  disease  indicated  as  a  cause  of  death  being  regarded  as  a 
I  will  ask  you  to  kindly  inform  me  of  the  primary  cause  of  the  death,  wl 
important  to  know  from  the  point  of  view  of  statistics,  as  well  as  from  the  point  of 
view  of  public  and  private  hygiene  of  the  sanitary  administration. 
Thanking  you  in  advance,  I  remain, 

Very  respectfully,  The  Director, 

Federal  Bureau  of  Statistics: 
Dr.  GUILLAUME. 

[On  the  opposite  page  are  the  questions.] 

What  are  the  sanitary  conditions  of  the  habitation? 

(Question  10  of  the  card  report  of  the  death. ) 

Hereditary  predisposition? 

Mode  of  infection? 

Accident,   suicide,  homicide? 

In  what  way  did  the  accident  occur? 

Probable  or  certain  motive  for  suicide?  ._ 


TERMINOLOGY    AND    ARRANGEMENT    OF    TERMS 

EMPLOYED  UPON   CERTIFICATES  OF  DEATH 

TO  DENOTE  CAUSES  OF  DEATH. 


Casual  examination  of  the  various  forms  of  certificates  of  death  will 
show  that  a  great  variety  of  expressions  has  been  employed  for  the 
purpose  of  securing  a  statement  of  cause  of  death.  These  may  be 
brought  together  for  comparison  in  the  following  tabular  list: 


First  term. 


Second  term.     (Subsequent  terms,  if  any.) 


The  CAUSE  OF  DEATH 

Chief 

Chief 

Immediate  ............... 

Cause  of  death 

Primary 

Chief 

Cause  of  death  (secondary  or  immediate) 

Disease  or  cause  of  death 

Primary1 


rn 
[1] 

Immediate 

True  cause  of  death 


Contributory. 

Contributory  (if  any). 

Immediate. 

Contributory. 

[No  second  term.] 

Contributory. 

Contributing. 

Contributory  (primary). 

[No  second  term.] 

Immediate  (when  a  complication  or  consequence 

of  the  primary).1 
f[2]  Immediate.1 


Primary 

Immediate '. 

Cause  of  death 

Primary 

Primary 

Causes  of  death  [in  order  of  occurrence] . 

Causes  of  death  [in  order  of  occurrence — physi- 
cian is  requested  to  underline  that  which  he 
considers  the  most  important] . 

/Immediate  and  determining 

\Immediate,proximate,or  chief  and  determining1 . 

Chief  and  determining 

[1]  Disease  causing  death 


[1]  Mode  of  injury;  accidental,  suicidal,  or  homi- 

lemote  or  predisposing  ........................... 

Disease,  injury,  or  other  efficient  and    remote 
cause  of  death. 

f]  immediate  .................................... 

Cause  of  death  (immediate)  ...................... 

Chief  or  primary  .................................. 

First  (primary)  .................................... 

First  or  primary  ................................... 

Primary  disease  ......  (a)  .......................... 


Primary  (actual) 
First 


Primary  or  contributing. 

Symptoms    (when    true    cause    is    not   certainly 

knoum).1 

Secondary  or  contributory. 
Contributory  causes  or  complications. 
Complication. 
Immediate. 
Secondary. 


Contributing  cause  or  complication. 
Contributory  causes  or  complications.1 
Consecutive  and  contributing. 
2]  Immediate  cause  of  death. 
3]  Contributory  causes  or  complications. 

Post-mortem. 
f[2J   Nature  of   injury  and  immediate   cause    of 

contributory  causes  or  conditions.1 
4]  Post-mortem. 
mmediate. 

Disease,  injury,  or  other  efficient  and  immediate 
cause  of  death. 


(b). 
). 


ame  of  disease  (remote). 
Contributory  or  immediate. 
Second  (immediate). 
Secondary. 

Secondary  diseases  (if  any) 
Secondary  diseases  (if  any) 
Secondary  diseases  (if  any) 
Secondary  (contributing). 
Second. 
2-  Secondary 
3.  Final. 


Disease  or  accident  causing  death  .................  {chronic 

Primary  disease  ...................................    Complications  of  the  disease  or  terminal  condi- 

tion. 
Primary  disease  ...................................    Secondary  or  after  disease. 

Principal  cause  ...............................  .....    Contributory  cause. 

[2]  Consecutive  disease  and  immediate  cause  of 

death. 
[3]  Concomitant  or  circumstantial  diseases  worth  y 

of  note. 

41  Autopsy:  Yes  -  ;  No  -  . 


[1]  Primitive  disease  or  primary  cause. 


[1]  Nature  and  cause  of  accident,  suicide,  etc 


Results  of  accidents. 


iFrom  instructions  or  alternative  modification  of  regular  form. 
(40) 


41 

What  a  conglomeration! 

Are  all  of  these  terms  and  their  relations  definitely  understood  by 
the  physicians  and  registrars  who  employ  them  ? 

It  may  be  well,  with  the  aid  of  certain  authorities  available  for  ref- 
erence, to  analyze  them,  and  to  see  just  what  meanings  may  be  attached 
to  the  more  important  ones. 

Some  of  the  terms  are  those  of  ordinary  language,  so  that  reference 
to  a  general  dictionary  should  be  sufficient.  Others  are  used  in  a  more 
or  less  technical  sense,  so  that  medical  dictionaries  would  seem  likely 
to  be  more  useful.  For  convenience  the  more  important  ones  will  be 
listed  in  alphabetical  order,  without  regard  to  their  usual  occurrence 
as  first  or  second  terms,  and  the  definitions  given  in  three  dictionaries 
in  common  use  in  the  United  States  will  be  compared:  (a)  Dorland: 
American  Illustrated  Medical  Dictionary;  (b)  Gould:  Illustrated  Dic- 
tionary of  Medicine,  Biology,  and  Allied  Sciences;  and  Dictionary  of 
New  Medical  Terms;  (c)  Webster's  International  Dictionary  of  the 
English  Language.  Omission  of  a  reference  shows  that  the  word  or 
term  is  not  defined  in  the  work  in  question. 

DEFINITIONS   OF   MORE    IMPORTANT   TERMS. 

Chief. — (c)  1.  Highest  in  office  or  rank;  principal;  head.  2.  Principal  or  most 
eminent  in  any  quality  or  action;  most  distinguished;  having  most  influence;  taking 
the  lead;  most  important.  Syn. — Principal;  head;  leading;  main;  paramount; 
supreme;  prime;  vital;  especial;  great;  grand;  eminent;  master.  [Note  that  pri- 
mary is  not  given  as  a  synonym.] 

Chief  cause. — [Not  specially  defined  in  any  medical  or  general  dictionary.  This 
term  was  probably  employed  upon  certificates  of  death  as  an  approximate  equiva- 
lent or  substitute  for  primary  cause,  but  without  retaining  the  idea  of  necessary 
priority  in  time  of  development  and  causal  relation  to  other  causes.  Some  modes  of 
use  upon  certificates  of  death  are  as  follows: 

First  term.  Second  term. 

Chief Contributory. 

Chief Immediate. 

Chief  and  determining Consecutive  and  contributing. 

Immediate  proximate  or  chief  and  determining. .    Contributory  causes  or  complications. 
Chief  or  primary ;  Contributory  or  immediate. 

The  transition  of  meaning  may  be  seen  in  these  groupings.  The  term  is  ambig- 
uous, meaning  either  (1)  most  important  (for  what?),  or  (2)  primary  (original). 
Thus,  in  a  death  from  typhoid  fever  followed  by  bronchopneumonia  (complication), 
the  "chief  cause  of  death"  might,  in  the  opinion  of  the  attending  physician,  be 
either  typhoid  fever  or  bronchopneumonia,  in  the  latter  case  the  secondary  disease 
or  condition  being  regarded  as  the  immediate  or  determining  factor,  and  hence  the 
most  important  as  directly  bringing  about  the  death,  which  might  not  have  occurred 
except  for  such  complication.] 

Complication. — (a)  1.  A  disease  or  diseases  concurrent  with  another  disease.  2. 
The  occurrence  of  twro  or  more  diseases  in  the  same  patient. 

(/))  A  disease  or  process  secondary  to  or  more  or  less  dependent  upon  some  primary 
disease. 


42 

(c)  (Med.)  A  disease  or  diseases,  or  adventitious  circumstances  or  conditions, 
coexistent  with  and  modifying  a  primary  disease,  but  not  necessarily  connected 
with  it. 

[This  term  is  always  used  in  a  subordinate  relation: 


First  term. 


Second  term. 


Primary 


Immediate 

Cause  of  death 

Immediate  and  determining. 
Primary  disease 


Immediate  (when  a  complication  or  consequence 
of  the  primary). 

Contributory  causes  or  complications. 

Complication. 

Contributing  cause  or  complication. 

Complications  of  the  disease  or  terminal  condi- 
tions. 


Complications  frequently  include  mere  symptoms,  and  the  term  is  apt  to  lead  to 
the  statement  of  inconsequential  details  upon  the  certificate  of  death.  Complica- 
tions are  frequently  understood  to  be  necessarily  secondary  in  character  to  the 
primary  disease,  but  they  may  equally  well  include  independent  intercurrent 
diseases.] 

Contributory  (or  contributing). —  (c)  Contributing  to  the  same  stock  or  purpose; 
promoting  the  same  end;  bringing  assistance  to  the  same  joint  design,  or  increase  to 
some  common  stock. 

Contributory  cause  (or  contributing  cause). — [This  term  is  not  given  in  medical  or 
general  dictionaries,  although  it  is  very  extensively  employed  in  the  United  States. 
It  is  found  upon  the  standard  certificate  of  death,  prepared  by  the  cooperation  of  the 
Census  and  the  American  Public  Health  Association,  which  is  used  for  the  tran- 
scripts of  all  deaths  (over  650,000  yearly)  returned  to  the  Bureau  of  the  Census,  as 
well  as  by  many  states  and  cities  upon  their  individual  blanks,  whether  of  standard 
or  other  form.  In  the  standard  certificate,  the  term  is  subordinate  to  the  "CAUSE 
OP  DEATH."  It  is  generally  secondary  in  character,  if  the  diseases  are  related  as  to 
cause  and  effect;  if  not  so  related,  it  may  connote  any  independent  disease  aiding  the 
principal  cause  of  death.  It  should  not  include  mere  symptoms  or  trivial  complica- 
tions which  do  not  materially  contribute  to  the  fatal  result.  In  modifications  of  the 
standard  certificate  used  in  different  states  and  cities  the  term  is  employed  in  various 
connections,  and  has  even  been  taken  as  the  primary  cause,  although  always  coming 
second  in  the  order  of  statement.  Among  the  arrangements  found  are  the  following: 


First  term. 


Second  term. 


CAUSE  OF  DEATH 

Chief 

Immediate 

Primary 

Cause  of  death  (secondary  or  immediate). 

Immediate 

Primary 

Immediate  and  determining 

Chief  and  determining 

Chief  or  primary 

Primary  (actual ) 


Contributory. 

Contributory. 

Contributory. 

Contributory. 

Contributory  (primary). 

Primary  or  contributing. 

Secondary  or  contributory. 

Contributing  cause  or  complication. 

Consecutive  and  contributing. 

Contributory  or  immediate. 

Secondary  (contributing). 


There  is  evidently  great  confusion  in  the  practical  use  of  this  term,  due,  perhaps, 
to  the  fact  that  all  causes  of  death  aiding  to  produce  the  fatal  result  in  any  case  are 
"contributory"  to  the  death.  The  term  does  not  mark  with  clearness  the  distinc- 
tion between  primary  and  secondary  or  concurrent  causes,  and  for  this  reason  the 
Bureau  of  the  Census,  and  it  is  believed  also  the  various  offices  using  the  standard 
blank,  wall  welcome  any  change  of  form  conducive  to  greater  precision  of  state- 
ment.] 


43 


Determining. 

Determining  cause. — (6)  A  cause  that  precipitates  the  action  of  another  or  other 
causes. 

[Only  a  single  definition  of  "determining  cause"  is  found  in  the  three  authorities 
consulted.  For  "determining,"  reference  may,  of  course,  be  made  to  the  various 
meanings  of  the  verb  determine,  as  found  in  any  general  dictionary;  but  which  precise 
signification  of  this  word  is  applicable  does  not  seem  certain.  The  term  "determin- 
ing cause"  is  extensively  used  relative  to  the  causation  of  disease,  and  considerably, 
but  to  a  less  extent,  upon  death  certificates.  Another  medical  dictionary 1  thus  defines 
it:  "A  cause  that  gives  efficiency  to  other  causes,  precipitating  their  action."  Both 
of  these  definitions  seem  to  make  determining  causes  of  merely  subsidiary  impor- 
tance, as  hastening  or  helping  the  action  of  other  (efficient)  causes.  Dr.  Lewellys 
F.  Barker2,  in  a  passage  which  may  be  quoted  in  full  for  the  purpose  of  showing  the 
relation  of  various  other  terms,  makes  it  equivalent  to  the  efficient,  proximate, 
immediate,  or  direct  cause. 

"All  pathologists  are  now  agreed  that  by  far  the  majority  of  pathologic  conditions 
are  the  result  of  external  causes;  i.  e.,  are  due  to  inimical  environmental  influences. 
These  are  divisible  into  (1)  efficient  causes  and  (2)  predisposing  and  accessory  causes 
of  disease. 

"The  efficient  causes  of  disease  (causx  proxlmse  sire  determinantes)  are  the  immediate 
or  direct  causes.  Thus  the  cholera-spirillum  is  the  efficient  cause  of  cholera,  the 
micrococcus  lanceolatus  is  the  efficient  cause  of  acute  lobar  pneumonia,  the  heat  of 
the  sun's  rays  of  insolation,  lead-poisoning  of  wrist-drop. 

"  The  predisposing  and  accessory  causes  of  disease  (causse  predisponantes  sire  remotss) 
include  those  which  render  the  body  more  susceptible  to  the  efficient  cause.  Thus, 
external  agents  which  render  the  contents  of  the  stomach  alkaline  are  believed  to 
predispose  to  infection  with  the  comma-bacillus  of  cholera;  exposure  to  cold  and  wet 
predispose  to  lobar  pneumonia;  alcoholism  predisposes  to  insolation;  and  certain 
occupations  make  lead-poisoning  possible,  and  in  a  sense  may  therefore  be  regarded 
as  remote  causes  of  lead  paralysis.  That  an  efficient  cause  of  one  disease  may  be  a 
predisposing  cause  of  another  disease,  and  vice  versa,  is  obvious." 

Stengel3  says,  "The  causes  of  disease  may  be  classified  as  predisposing  and  deter- 
mining. The  former  prepare  the  system  or  part  by  rendering  it  weaker  and  less 
resistant;  the  latter  are  the  immediate  or  specific  causes  of  disease,"  and,  under 
"Determining  causes,"  he  says:  "Among  the  immediate  or  determining  causes  of 
disease  are  those  which  originate  outside  the  body  and  those  which  are  generated 
within  the  body.  Among  the  former  are  included  traumatism,  heat,  cold,  and 
living  organisms,  including  bacteria  and  various  animal  parasites."  As  the  deter- 
mining (=  efficient = proximate  =  immediate  =  direct)  cause  of  a  disease,  e.  g., 
typhoid  fever,  is  the  bacillus  typhosus,  so  the  disease  itself  (the  pathologic  entity 
called  typhoid  fever,  with  all  its  complications  and  sequelae)  is  sometimes  taken  as 
the  determining  (=  efficient  =  proximate  =  immediate  =  direct)  cause  of  death.  As 
found  upon  death  certificates,  the  term  occurs  always  in  combination,  and  in  the 
first  place: 


First  term. 

Second  term. 

Immediate  and  determining  .  . 

Contributing  cause  or  complication 

Immediate  proximate  or  chief  and  determining.. 
Chief  and  determining  

Contributory  causes  or  complications. 
Consecutive  and  contributing 

1  Foster:  An  Encyclopedic  Medical  Dictionary. 

2  Introduction,  American  Textbook  of  Pathology, 
s. A  Text  Book  of  Pathology,  third  edition,  page  18. 


44 

However  useful  the  word  may  be  in  connection  with  causes  of  disease,  its  employ- 
ment in  connection  with  causes  of  death  is  vague  and  indefinite.] 

Immediate. — (a)  Direct;  with  nothing  intervening. 

(6)  Direct;  withou t  anything  intervening. 

(c)  1.  Not  separated  with  respect  to  place  by  anything  intervening;  proximate; 
close.  2.  Not  deferred  by  an  interval  of  time;  present;  instant.  3.  Acting  with 
nothing  interposed  or  between,  or  without  the  intervention  of  another  object  as  a 
cause,  means,  or  agency;  acting,  perceived,  or  produced,  directly;  as  an  immediate 
cause. 

Immediate  cause. — (a)  An  exciting  cause  that  is  not  remote  or  secondary;  any 
cause  'which  is  operative  at  the  beginning  of  an  attack. 

(6)  See  C.,  Proximate;  and,  making  the  reference,  we  find  that  primary  and 
proximate  causes  are  thus  defined:  "C.,  Primary,  C.,  Proximate,  that  one  of 
several  causes  which  takes  effect  last  and  acts  with  rapidity." 

[Another  medical  dictionary  (Dunglison)  refers  the  term  to  "  essential  or  proxi- 
mate cause,"  an  essential  cause  being  defined  as  "one  that  produces  the  effect  with- 
out regard  to  other  causes."  See  identity  with  efficient,  proximate,  determining,  and 
direct  causes  of  disease,  as  used  by  writers  on  pathology,  under  "Determining  cause," 
supra.  The  term  is  very  frequently  and  most  confusingly  employed  upon  certificates 
of  death  in  this  country : 


First  term. 


Second  term. 


Chief 

Immediate 


Immediate. 
Contributory. 


Cause  of  death  (secondary  or  immediate)  ........  I  Contributory  (primary). 

Primary  ...........................................  !  Immediate  (complication  or  consequence  of  the 

primary). 

m  RpmotP  7L2J  Immediate. 

[1]  Remote  ........................................  UhJ  Concurring. 

Immediate  ........................................  |  Primary  or  contributing. 

Immediate  ........................................  i  Contributory  causes  or  complications. 

Primary  ...........................................  !  Immediate. 

Immediate  and  determining  ......................    Contributing  cause  or  complication. 

m  nispncp  r>an«ino-riPflth  /I2]  Immediate  cause  of  death. 

Disease  causing  death  .........................  ^3j  Contributory  causes  or  complications. 

Remote  or  predisposing  ...........................  ;  Immediate. 


PI 

Primitive  disease  or  primary  cause  of  death  ......  i  Consecutive    disease    and    immediate    cause    of 

death. 

In  its  practical  use  upon  certificates  of  death  it  has  at  least  three  distinct  meanings: 
(1)  As  a  term  subordinate  to  the  principal  term  ("Chief  cause,"  "Primary  cause," 
"  Remote  cause,"  "Disease  causing  death,"  etc.  ),  and  indicating  the  special  patholog- 
ical process,  condition,  or  complication  through  which  the  disease  itself,  or  primary 
cause,  brings  about  the  fatal  result.  Thus,  in  a  case  of  typhoid  fever  the  on  mediate 
cause  of  death  might  be  a  secondary  pneumonia,  perforation  of  the  intestine,  peri- 
tonitis, or  hemorrhage  of  the  bowels,  all  consequences  and  properly  a  part  of  the 
original  disease.  In  the  only  foreign  blank  in  which  this  term  occurs,  that  of  Switz- 
erland, it  appears  to  bb  used  in  this  way.  (2)  In  a  very  different  manner,  the  term 
is  employed  to  indicate  the  principal  or  even  primary  cause  of  death,  being  followed 
by  subordinate  terms,  such  as  "Contributory  cause,"  "Primary  or  contributing 
cause,"  "  Contributory  causes  or  complications,"  etc.  (3)  In  common  with  the 
synonymous  term,  proximate  cause,  it  is  frequently  understood  by  physicians  as 
merely  indicating  the  mode  of  death,  e.  g.,  asphyxia,  "heart  failure"  or  syncope, 
coma,  etc.  Thus  Quain's  Dictionary  of  Medicine,  under  "Death,  modes  of,"  says, 
"The  proximate  causes  of  death,  whether  resulting  from  natural  decay,  disease,  or 
violence,  may  be  reduced  in  ultimate  analysis  to  two,  namely,  first,  cessation  of  the 
circulation;  and,  second,  cessation  of  respiration."  "Shock,"  "debility,"  "exhaus- 
tion," and  also  terms  representing  terminal  conditions,  such  as  "hypostatic  pneumo- 


45 

nia,"  "uremic  convulsions,"  and  the  like,  are  frequently  reported  as  the  immediate 
causes  of  death.] 

Primary. — (a)  First  in  order;  principal. 

(6)  First  in  time  or  in  importance. 

(c)  1.  First  in  order  of  time  or  development  or  intention;  primitive;  fundamental; 
original.  2.  First  in  order  as  being  preparatory  to  something  higher.  3.  First  in 
dignity  or  importance,  as  chief,  principal. 

[There  are  other  significations  of  the  word  ''primary"  as  employed  to  qualify 
names  of  diseases  or  causes  of  death,  as  indicated  by  the  definition  in  the  New 
Sydenham  Society's  Lexicon:  "Primary.  (L.  primarius,  of  the  first  rank.)  A  term 
used  in  a  variety  of  senses  in  medicine;  e.  g.,  to  denote  the  original  site  of  a  disease 
(primary  seat  of  a  new  growth),  or  its  earliest  manifestations  (primary  syphilis); 
often  used  in  opposition  to  secondary,  in  cases  in  which  the  morbid  condition  so 
indicated  is  viewed  as  the  main  disease,  and  not  as  a  secondary  effect,  e.  g.,  primary 
lateral  sclerosis  =  idiopathic  lateral  sclerosis."] 

Primary  cause. — (a)  The  principal  or  original  cause  of  an  attack. 

(b]  C.,  Proximate,  that  one  of  several  causes  which  takes  effect  last  and  acts  with 
rapidity. 

[See  also  another  medical  dictionary  (Foster):  "Primary  cause,  proximate  cause. 
That  one  of  two  or  more  causes  that  comes  into  play  last  and  produces  its  effect  with 
comparative  rapidity."  The  last  two  definitions  seem  at  variance  with  the  first,  and 
explain  how,  the  immediate  (proximate)  and  primary  causes  of  disease  being  con- 
sidered the  same,1  so  likewise  the  immediate  and  primary  causes  of  death  come  to 
be  treated  as  identical.  In  England,  at  least  in  its  official  use  for  registration  pur- 
poses, the  term  has  been  uniformly  employed  to  show  precedence  in  time  or  causal 
relation.  In  the  First  Annual  Report  of  the  Registrar-General  (1837),  Doctor  Farr 
stated:  "When  after  hooping  cough  it  was  stated  that  the  patient  died  of  pneu- 
monia, the  case  has  been  referred  to  the  primary  disease;  and  the  same  principle 
has  been  adhered  to  in  similar  instances."  And  in  the  Thirteenth  Annual  Report: 
"It  has  been  the  general  rule,  in  the  classification,  to  refer  the  secondary  affections 
that  supervene  in  the  course  of  measles,  scarlatina,  phthisis,  and  other  diseases,  to 
the  primary  diseases  by  which  they  are  caused  or  modified,  and  the  diseases  that 
are  the  direct  result  of  external  causes  to  those  causes."  The  certificates  of  death 
supplied  to  physicians  as  early  as  1845  provided  for  the  statement  of  primary  and 
secondary  causes,  as  do  those  in  use  at  the  present  time  in  Great  Britain  and  many 
of  the  British  colonies.  Up  to  a  recent  date  the  "Suggestions  to  Medical  Practi- 
tioners respecting  Certificates  of  the  Cause  of  Death"  2  contained  the  following  para- 
graph: "Write  the  causes  of  death,  when  there  are  more  than  one,  under  each  other, 
in  the  order  of  their  appearance,  and  not  in  the  presumed  order  of  their  importance." 
The  accepted  English  arrangement  (primary,  secondary)  is  of  very  infrequent  occur- 
rence in  this  country,  the  term  primary  cause  being  usually  opposed  by  some  other 
term,  as  contributory  cause,  immediate  cause,  etc.,  as  shown  by  the  following 
comparison: 


First  term. 

Second  term. 

Primary 

Contributory 

Cause  of  death  (secondary  or  immediate)  

Contributory  (primary). 

Primary 

Immediate 

Immediate  

Primary  or  contributing. 

Primary 

Secondary  or  contributory. 

Primary  

Secondary. 

Chief  or  primary 

Contributory  or  immediate. 

First  (primary)  

Second  (immediate). 

!Cf.  Barton-Wells,  Thesaurus  of  Medical  Words  and  Phrases:  "Immediate  cause  of  disease— Essen- 
tial, proximate,  or  primary  cause,"  and  "Predisposing  cause  of  disease — Antecedent,  procatarctic 
remote,  or  secondary  cause." 

2 See  Newsholme's  Vital  Statistics,  third  edition,  page  72. 


46 

Even  in  England,  after  over  sixty  years  of  continuous  use  of  the  terms  "primary" 
and  "secondary"  upon  the  official  blanks,  there  is  confusion  as  to  their  proper 
significance  in  the  minds  of  many  medical  practitioners.  Following  are  the  conclu- 
sions of  the  Select  Committee  on  Death  Certification  of  the  House  of  Commons 
(1893)  on  this  subject,  together  with  the  testimony  upon  which  they  were  based: 

Hicks,  1325.  (C.)   It  appears  that  there  is  some  confusion  in  the  minds  of  medical 

Tatham,  2010.    men  as  to  the  meaning  to  be  attached  to  the  words  "primary"  and 

Vallance,  2267.    "secondary,"  in  the  space  provided  in  the  form  for  setting  foVth  the 

Grimshaw,  775.  cause  of  death.     The  words  are  interpreted  by  some  as  meaning  the 

Sykes,  450.          "primary  cause  chronologically,  and  by  others  as  the  primary  cause 

phj-sically  of  death."     The  forms  are  filled  up  in  accordance  with  these 

different  interpretations. 

Sykes,  450.  The  result  of  this  is  that  in  many  instances  the  certificate  does  not 

Wells,  691.  give  correct  information  as  to  the  cause  of  death,  and  it  is  difficult  for  a 
person  from  mere  inspection  of  the  certificate,  and  without  having  seen 
the  patient,  to  say  what  was  the  immediate  cause  of  death. 

Your  committee  are  of  opinion  that  it  is  desirable  that  the  words 
"primary"  and  "secondary"  should  either  be  omitted  from  the  form 
as  leading  to  confusion  in  stating  the  cause  of  death,  or  that  they 
should  be  defined  in  a  footnote  as  meaning  the  order  of  the  develop- 
ment of  the  diseases  as  they  occurred.  In  the  event  of  the  entire 
omission  of  the  words,  some  other  terms  should  be  substituted  so  as  to 
secure  the  declaration  in  all  cases  of  associated  diseases  or  associated 
traumatic  conditions. 

[Testimony.] 

450.  [Mr.  J.  F.  J.  Sykes,  M.  B.]     ^yill  you  tell  the  committee  now, 
as  briefly  as  you  can,  the  directions  in  which  you  think  the  present 
system  of  certification  is  defective  as  regards  the'causes  of  death? — The 
difficulty  arises  when  those  who  have  to  extract  these  causes  of  death 
and  classify  them,  find  either  a  number  of  terms  not  used  in  the  ordi- 
nary form  of  classification,  or  else  a  multitude  of  terms  without  any 
guide  as  to  which  of  the  several  terms  the  death  should  be  classified 
under,  and  it  is  extremely  difficult  for  persons  seeing  only  the  certifi- 
cate, and  not  the  patient,  "to  know  the  real  cause,  the  true  cause  from 
which  the  patient  died,  and  under  which  the  death  should  be  classi- 
fied.    The  certificate  of     the  Registrar-General  contains  under  the 
"Cause  of  death,"  the  words   "primary"  and  "secondary."     In  my 
opinion  those  are  more  misleading  than  useful,  for  this  reason:  that 
they  are  interpreted  by  some  as  being  the  primary  cause  chronolog- 
ically, and  by  others  as  the  primary  cause  physically  of  death;  so  that 
the  two  interpretations  that  they  are  open  to  do  not  coincide.     And 
as  far  as  chronological  order  is  concerned,  they  are  unnecessary,  inas- 
much as  at  the  other  end  of  the  line  under  the  "cause  of  death"  there 
is  a  space  for  stating  the  duration  of  each  cause  in  years,  months,  days, 
or  hours.     I  would  suggest  that  the  words  "primary"  and  "second- 
ary" should   be  omitted  altogether  from  the  certificate,  and  that  it 
should  be  made  compulsory  to  state  the  duration  of  the  complaint  or 
the  approximate  duration,  so  as  to  form  some  sort  of  guide  as  near  as 
possible. 

451.  You  think  those  terms  lead  to  confusion? — I  think  those  terms 
lead  to  confusion. 

691.  [Sir  Spencer  Wells,  M.  D.,  F.  R.  C.  S.]     And  in  what  way; 
would  you   give  us  an  illustration  of  that  insufficiency? — That  the 
registered  cause  of  death  was  not  sufficiently  precise;  that  one  could 
not  tell  from  the  terms  exactly  what  weia  the  alleged  causes  of  death; 
that  they  were  inaccurate  and  insufficient;  that  you  want  full  informa- 
tion as  to  the  cause  of  death. 

692.  And  you  believe  that  fuller  and  more  detailed  information  of 
the  cause  of  death  would  lead  to  a  greater  value  being  given  to  the  sta- 
tistics of  the  Registrar-General,  and  secondarily  (and  this  is  a  most 
important  point)  to  an  improvement  in  the  national  health? — Distinctly. 

775.  [Thomas  W.  Grimshaw,  M.  D.,  Registrar-General  for  Ireland.] 
With  regard  to  that  we  have  had  evidence  given  here  that  the  division 
of  the  causes  of  death  into  primary  and  secondary  is  undesirable.  What 
is  your  opinion  upon  that  subject? — It  would  not  be  undesirable  if 


47 

properly  used,  but  there  is  a  great  deal  of  confusion  in  the  minds  of 
medical  men  as  to  what  is  primary  and  what  is  secondary. 

776.  Would  you  suggest  the  omission  of  those  words  or  the  substi- 
tution of  others? — I  do  not  know  really  any  way  in  which  we  could 
amend  the  certificate  so  as  to  get  rid  of  that  ambiguity,  because  it  is  in 
the  mind  of  the  man  who  certifies,  it  is  not  in  the  form  of  the  certifi- 
cate. If  we  could  get  a  specific  cause  mentioned  and  then  get  the  med- 
ical man  to  add  a  descriptive  note  as  to  how  this  state  of  things  was 
arrived  at  which  caused  the  man  to  die,  it  might  be  of  very  great  value; 
but  I  do  not  think  we  could  succeed  in  doing  that.  If  we  were  to  ask 
him  to  voluntarily  give  us  any  other  information  that  threw  light  upon 
the  case,  he  might  do  so,  but  he  might  become  a  very  great  nuisance; 
some  would  write  a  great  deal  too  much. 

1325.  [Mr.  A.  B.  Hicks,  coroner,  London.]     Do  you  want  the  words 
"primary"  and  "secondary"  altered? — I  wish  to  put  in  the  primary 
cause  with  the  duration  of  the  illness,  and  the  secondary  cause  also, 
and  then,  if  there  is  one,  the  immediate  cause  of  death. 

1326.  Then  you  would  still  retain  the  words   "primary"  and  "sec- 
ondary"?— They  are  somewhat  misleading,  I  think.     I  do  not  say  I 
would  insist  myself  upon  them,  but  at  any  rate  there  should  be  some 
words  which  may  really  lead  to  the  cause  of  the  decease,  if  the  doctor 
knows  it,  and  how  it  runs  its  course,  with  the  symptoms;  that  it  is 
essential  to  get,  and  then  the  immediate  cause  of  death,  if  he  knows  it. 
Then  I  should  suggest  a  note  at  the  bottom  of  the  certificate,  which  he 
should  fill  up,  if  he  can:  "Facts  which  may  be  known  to  the  medical 
man  wrhich  may  bear  upon  the  cause  of  death,  and  which  he  considers 
desirable  to  state." 

2010.  [Mr.  John  Tatham,  M.  A.,  M.  D.,  then  medical  officer  of  health 
for  Manchester,  now  statistical  superintendent  of  the  department  of  the 
Registrar-General  of  England  and  Wales.]  If  you  would  kindly  make 
such  remarks  as  you  think  fit. — I  think  in  the  first  place  that  the  space 
left  for  the  cause  of  death  should  be.  enlarged.  I  think  it  should  also 
be  explained  what  is  the  real  meaning  of  the  terms  "primary"  and 
"secondary  " — whether  they  refer  to  time  or  to  the  relative  importance 
of  the  causes  of  death.  That  is  a  point  upon  which  certificates  are  fre- 
quently indefinite.  As  I  have  said  before,  I  think  the  certificates  should 
be  delivered  to  the  registrar  direct,  and  I  attach  very  great  importance 
to  that. 

2267.  [Mr.  William  Vallance,  superintendent  registrar,  Whitechapel 
district.]  You  say  that  you  have  reason  to  believe  that  there  is  a  good 
deal  of  lax  certification  both  as  regards  the  mode  of  filling  up  the  cause 
of  death  and  the  circumstances  under  which  the  certificate  is  given. 
Will  you  illustrate  that  point? — I  consider  that  the  words  "During  the 
last  illness"  require  some  explanation  as  to  what  is  to  constitute  the 
attendance  during  the  last  illness,  and,  therefore,  appended  to  the  cer- 
tificate it  appears  to  me  there  needs  to  be  an  instruction  to  the  medical 
practitioner.  And  next,  with  regard  to  the  cause  of  death,  the  words 
"primary"  and  "secondary"  are  somewhat  misleading,  or,  at  all 
events,  they  are  differently  interpreted;  so  that  if  statistical  results 
are  recorded  from  one  or  the  other  they  may  be  fallacious  in  their 
results.  I  would  much  prefer  myself — I  think  it  would  be  much  more 
simple — if  the  actual  disease  which  is  the  immediate  cause  of  death 
were  recorded  in  the  column  headed  "Cause  of  death,"  with  the  dura- 
tion of  the  disease,  and  an  observation  column  appended,  not  for  reg- 
istration but  for  transmission  to  the  statistical  authority. 

The  committee  did  not,  however,  suggest  the  "other  terms"  which  should  satis- 
factorily replace  those  in  use. 

Secondary. —  (a)  Second  or  inferior  in  order  of  time,  place,  or  importance. 

(6)  Following,  succeeding  to  a  first.  Subordinate  in  order  of  time  or  develop- 
ment. 

(c)  Succeeding  next  in  order  to  the  first;  of  second  place,  origin,  rank,  etc.;  sub- 
ordinate; not  of  the  first  order  or  rate;  not  primary.  (Med.}  a.  Dependent  or  con- 
sequent upon  another  disease;  as,  Bright' s  disease  is  often  secondary  to  scarlet  fever. 
6.  Occurring  in  the  second  stage  of  a  disease;  as,  the  secondary  symptoms  of  syphilis. 


48 

Secondary  cause. — (a.)  One  which  helps  to  bring  on  an  attack  of  disease.  [Another 
dictionary  (Dunglison)  refers  "remote  or  secondary  cause"  to  "predisponent cause; 
one  which  renders  the  body  liable  to  disease."  It  is  evident  that  these  definitions 
relate  to  the  secondary  cause  of  disease  and  that  they  are  quite  the  opposite,  in  time 
relation,  to  the  sense  in  which  the  term  is  used  as  applying  to  causes  of  death. 
Although  the  proper  associate  of  primary  cause  (q.  v.),  the  term  is  quite  rarely  used 
in  this  country  upon  certificates  of  death,  and  when  used  is  probably  frequently 
understood  in  the  sense  of  minor  rather  than  according  to  the  original  statistical 
usage  of  consecutive  and  resulting  from  the  primary  cause.  Some  examples  of  use  are 
as  follows] : 


First  term. 


Second  term. 


Primary \  Secondary  or  contributory. 

Primary |  Secondary. 

Secondary  (contributing). 


Primary  (actual ) 

Cause  of  death  (secondary  or  immediate). 


Contributory  (primary). 


Only  the  more  important  terms  that  actually  occur  upon  certificates 
of  death  are  considered  in  the  preceding  examination  of  definitions. 
These  are:  "Chief  cause,"  "complication,"  "contributory  (or  con- 
tributing) cause,"  "determining  cause,"  "immediate  cause,"  "pri- 
mary cause,"  and  "  secondary  cause."  Other  terms  occurring  less  fre- 
quently, or  used  chiefly  in  instructions,  are  :  "  Concurrent  (or  concur- 
ring) cause,"  "consecutive  cause,"  "consequence,"  "efficient cause," 
"final  cause,"  "predisposing  (predisponent)  cause,"  "remote  cause," 
"sequela,"  "symptom,"  and  "terminal  cause."  Among  these  the  fol- 
lowing are  defined : 

DEFINITIONS   OF    LESS    IMPORTANT    TERMS. 

Concurrent — (c)  1.  Acting  in  conjunction;  agreeing  in  the  same  act  or  opinion; 
contributing  to  the  same  event  or  effect;  cooperating.  2.  Conjoined*  associate;  con- 
comitant; existing  or  happening  at  the  same  time. 

["Concurrent  cause"  or  "concurrent  disease"  is  not  found  in  the  authorities 
cited,  but  "  intercurrent  disease"  appears  as  follows:  (a)  "A  disease  occurring  during 
the  course  of  another  disease  with  which  it  has  no  connection."  (6)  "A  disease 
occurring  during  the  progress  of  another  of  which  it  is  independent,"  and  also,  else- 
where, "A  term  loosely  applied  to  diseases  occurring  sporadically  during  a  period  of 
prevailing  endemic  or  epidemic  diseases.  Also  applied  to  a  disease  arising  or  pro- 
gressing during  the  existence  of  another  disease  in  the  same  person."] 

Efficient  cause. — (c)  The  agent  or  force  that  produces  a  change  or  result. 

Final  cause. — (c)  The  end,  design,  or  object  for  which  anything  is  done. 

[Not  used  in  this  sense  upon  certificates  where  it  means  a  terminal  cause,  i.  e., 
symptoms  or  conditions  attending  the  fatal  termination  of  the  disease.] 

Predisposing  (or  predisponent}  cause. — (a)  Anything  which  renders  a  person  liable 
to  an  attack  of  disease  without  actually  producing  it. 

(b]  That  which  tends  to  the  development  of  a  condition. 

(c)  (Med.)  Causes  which  render  the  body  liable  to  disease. 

Proximate  cause. — (a)  That  which  immediately  precedes  and  produces  a  disease. 
(6)  The  immediate  cause  of  any  change. 

(c)  A  cause  which  immediately  precedes  and  produces  the  effect,  as  distinguished 
from  the  remote,  mediate,  or  predisposing  causes. 


49 

[Usually  equivalent  to  immediate  cause.  The  new  Sydenham  Society's  Lexicon 
thus  defines  it:  "The  term  is  used  by  some  in  the  sense  of  the  disease  itself;  by 
others  as  meaning  those  morbid  processes  which  the  exciting  cause  induces;  by 
others  as  denoting  the  morbific  cause  itself."  The  same  causes  may  be  either 
"  proximate  "  or  "  ultimate,"  according  to  the  previous  direction  of  thought:  (Quain's 
Dictionary  of  Medicine;  "Death,  modes  of.")  "The  proximate  causes  of  death, 
whether  resulting  from  natural  decay,  disease,  or  violence,  may  be  reduced  in  ulti- 
mate analysis  to  two,  namely,  first,  cessation  of  the  circulation;  and,  second,  cessa- 
tion of  respiration,"  (Flint's  Encyclopedia  of  Medicine  and  Surgery;  Death,  modes 
of.)  "Failure  of  the  heart  or  of  the  respiratory  mechanism  is  always  the  ultimate 
cause  of  death."] 

Remote  cause. — (a)  Any  cause  which  is  not  immediate  in  its  effect;  a  predisposing, 
secondary,  or  ultimate  cause. 

Sequela. — (a)  Any  lesion  or  affection  following  and  caused  by  an  attack  of  disease. 

(b)  The  consequence  or  abnormal  condition  following  an  injury  or  the  abatement 
of  a  disease;  any  diseased  or  abnormal  condition  that  folio ws  an  attack  of  disease  or 
an  injury. 

(c)  ( Med. )  A  morbid  phenomenon  left  as  the  result  of  a  disease;  a  disease  resulting 
from  another. 

Symptom. — (a)  Any  evidence  of  disease  or  of  a  patient's  condition;  a  change  in  a 
patient's  condition  indicative  of  some  bodily  or  mental  state. 

(b)  That  change  or  phase  which  occurs  synchronously  with  a  disease  and  serves  to 
point  out  its  nature  and  location. 

(c)  Any  affection  which  accompanies  disease;  a  perceptible  change  in  the  body  or 
its  functions,  which  indicates  disease,  or  the  kind  or  phases  of  disease. 

Terminal  cause. — [Not  defined.     But  see  "Final  cause"  above.] 
Ultimate  cause. — (a)  One  which  may  be  considered  the  original  cause  in  point  of 
time;  the  most  remote  cause. 

(6)  One  which  eventually  comes  into  play  aided  by  a  proximate  cause. 

To  these  definitions  might  be  added  two  others  which  are  frequently 
to  be  considered  in  vital  statistics,  although  not  expressly  stated: 

Hidden  cause. — An  undiscoverable  cause. 

Obscure  cause. — (L.  obscurus,  dark.)     A  cause  not  definitely  known. 

APPLICATION    OF   TERMS    IN    CERTIFYING   CAUSES   OF    DEATH. 

It  is  evident  in  comparing  the  definitions  of  various  causes  as  found 
in  medical  and  general  dictionaries  and  works  of  reference,  and  which 
the  physician  would  ordinarily  consult  in  attempting  to  understand  the 
requirements  of  the  official  blanks,  that  they  relate  almost  exclusively 
to  causes  of  disease  and  do  not  apply  to  causes  of  death  except  by  impli- 
cation or  transference  of  meaning.  It  is  not  surprising,  therefore, 
that  their  use  in  the  latter  connection  is  not  well  defined.  Thus,  the 
Bacillus  typhosus  is  the  efficient,  proximate,  immediate,  determining, 
or  direct  cause  of  the  disease  known  as  typhoid  fever;  it  has  also  been 
termed  the  primary  cause,  in  which  case  all  antecedent  causes  would 
be  termed  secondary.  Typhoid  fever  itself,  the  disease  resulting  from 
an  invasion  of  the  typhoid  bacillus,  is  the  primary  cause  of  death  in  a 
fatal  case  of  typhoid  fever;  it  may  also  be  reported  as  the  immediate, 
determining,  or  direct  cause  of  death.  The  disease-entity  known  as 
9159—07 4 


50 

typhoid  fever  properly  includes  all  of  the  secondary  pathological  con- 
ditions and  processes  resulting  from  the  development  of  the  specific 
infection,  such  as  ulceration  of  the  intestinal  Lymph-follicles,  perfora- 
tion of  the  intestine  and  resulting  peritonitis,  intestinal  hemorrhage, 
bronchopneumonia  or  lobar  pneumonia  clue  to  the  typhoid  bacillus 
(but  not  independent  intercurrent  pneumonia  due  to  Pneumococcus), 
terminal  phenomena  such  as  hypostatic  pneumonia  from  impairment  of 
circulation,  and  modes  of  dying — "  heart  failure,"  exhaustion,  debility, 
coma,  and  the  like.  Any  of  the  secondary  affections,  or  even  terminal 
conditions  and  modes  of  d}ang,  is  likely  to  be  entered  upon  the  certifi- 
cate of  death  as  the  proximate,  immediate,  direct,  or  determining 
cause  of  death;  or  even,  when  the  form  of  the  blank  facilitates  it,  as 
the  primary  or  chief  cause  of  death,  leaving  the  disease  itself  in  the 
position  of  a  secondary,  contributory,  or  remote  cause,  if  reported 
at  all. 

In  considering  the  application  of  various  terms  to  the  certification 
of  deaths,  the  broad  and  fundamental  distinction  necessary  in  vital 
statistics  must  be  borne  in  mind.  All  deaths  are  divided  into  two 
great  classes,  namely,  (1)  deaths  from  disease,  and  (2)  deaths  from  vio- 
lence. A  third  subdivision,  due  solely  to  imperfections  in  the  returns 
or  impossibility  of  securing  exact  information  to  make  the  distinction, 
would  include  deaths  the  causes  of  which  are  absolutely  "unknown." 
It  should  not  include  deaths  from  ill-defined  diseases  or  from  violence 
whose  exact  character  is  not  certain.  Such  deaths  should  at  least  be 
distinguished  as  due  to  diseases  of  unknown  or  unspecified  nature,  or 
as  due  to  traumatism  or  some  unknown  form  of  violence.  It  may  be 
mentioned  that  the  term  ""violence"  is  an  entirel3r  general  one  and 
includes  all  deaths  not  due  to  disease;  poisons  (not  autointoxications 
proper),  effects  of  weather  agencies,  as  sunstroke,  etc.,  are  included  as 
well  as  the  usual  forms  of  violence  due  to  accident  or  negligence, 
suicide,  homicide,  war,  and  execution. 

(1)  Deaths  from  disease. 

As  an  illustration  of  the  complexity  of  the  relations  involved  and 
of  the  necessity  for  a  precise  understanding  of  the  terminology  to  be 
employed  in  reporting  causes  of  death,  a  not  unusually  complicated 
fatal  case  of  typhoid  fever  may  be  selected. 


51 


Causation,  course,  and  fatal  termination  of  case  of  typhoid  fever. 


Phenomena. 


A.  CAUSATION  OF  DISEASE. 


(1)  A  previous  case 

(2)  Dejecta    containing    typhoid 
bacilli,  not  disinfected. 

t :'  i  A  young  man, 


Cause  of  disease. 


(4)  whose  "vital  resistance" 
("opsonic  index"?)  maybe  low- 
ered by  insanitary  conditions, 
e.  g.,  tilth,  crowding,  bad  air, 
adulterated  or  insufficient  food, 

<5)  drinks  infected  water  or  milk 
which  con  tains  - 

(6)  Bacillus  typhosus  (the  "ty- 
phoid germ"). 


Ultimate;    remote;  anteced- 
ent. 
Remote;  antecedent 


Age  and  sex  are  predispos- 
ing causes. 

Accessory;  predisposing;  re- 
mote; contributory.- 


Accidental;  occasional;  re- 
mote. 

Specific;  efficient;  proximate; 
determining;  immediate; 
direct.  [Also  called  pri- 
mary, in  which  case  all 
antecedent  causes  become 
secondary.] 

[Causation  of  disease  ends.] 


Cause  of  death. 


[All  causes  of  disease  are,  of 
course,  more  or  less  remote 
causes  of  resulting  deaths. 
They  do  not  enter  into  the 
formal  statement  of  cause  of 
death.] 


B.  COURSE  OF  DISEASE.  j  Disease  processes  or  conditions. 

(7)  After  the  usual  period  of  incu-  '  The    disease    itself.     [Also 

bation     the     disease     TYPHOID  called    the    proximate 

FEVER  is  recognized,  a  general  cause.] 
infection. 


(8)  It  is  characterized  by  ulcera- 
tion  of  the  lymph-follicles  of  the 
intestines. 

(9)  Perforation  of  bowel  may  re- 
sult. 

(10)  Peritonitis  may  follow 

(11)  A    pneumonic   process   may 
exist  from   the  start   (primary 
"  pneumo-typhus")  or  develop 
in  the  course  of  the  disease  (sec- 
ondary), due  to  invasion  of  ty- 
phoid bacilli. 

(12)  An    independent    (primary) 
acute  lobar  pneumonia  may  oc- 
cur, clue  to  Pneumococcus  infec- 
tion. 


Pathologic  process 

Complication 

Complication 


Complication;    pneumonic 
type  of  disease. 


Complicating  disease;  com- 
plication; concurrent  or 
intercurrent  disease. 


[Causation  of  death  begins.] 

Disease  causing  death;  cause  of 
death;  primary,  first,  chief, 
actual,  principal,  or  original 
cause  of  death  or  disease.  [Also 
reported  as  immediate,  proxi- 
mate, determining,  remote,  pre- 
disposing, and  contributory 
causes  of  death.] 

Sometimes  reported  as  cause  of 
death. 

Secondary;  contributory;  imme- 
diate. 

Secondary:  contributory;  imme- 
diate. 

Secondary;  contributory;  imme- 
diate. 


Contributory;  immediate;  second- 
ary (in  time);  concurrent;  in- 
tercurrent. 


C.  PROCESS  OF  DYING. 

(13)  Hypostatic  pneumonia  may 
result  from  failure  of  circula- 
tion. 


Terminal  condition;  compli- 
cation. 


(14)  Death  finally  results  (Bichat)  Terminal  symptoms; 
from  interference  with  the  func-  of  death  or,  rather, 
tions  of  the  brain  (coma),  heart  of  dying, 
("heart  failure,"  syncope),  or 
lungs  (apnea,  asphyxia);  or  from 
asthenia,  collapse,  debility,  ex- 
haustion, etc. 


modes 
modes 


[Frequently  returned  as  second- 
ary, contributory,  or  immediate 
cause  of  death.  Not  a  proper 
cau-e  of  death.] 

[Modes  of  death  should  not  be 
returned  as  causes  of  death  when 
the  latter  can  be  ascertained.] 


D.  POST-MORTEM  APPEARAM  KS. 

(15)  The  disease  itself,  or  its  com- 
plications, may  cause  certain 
lesions  evident  on  post-mortem 
examination,  as  typhoid  ulcers, 
necrosis  and  perforation  of  the 
bowel,  etc. 


Pathologic  findings;  lesions. 


[Post-mortem  findings,  as  such, 
should  not  be  given  as  the  cause 
of  death,  but  the  disease  should 
be  named  from  whiph  they 
result.] 


In  such  an  instance,  what  should  the  attending  physician  report 
upon  the  certificate  as  the  cause  of  death  ? 


-52 

The  question  may  be  simplified  by  first  considering  what  he  should 
not  report,  namely,  any  of  the  items  coming  under  the  subdivisions 
(A)  Causation  of  disease,  (C)  Process  of  dying,  and  (D)  Post-mortem 
appearances.  All  of  the  information  desired  pertains  to  (B)  Course  of 
disease.  It  should  be  understood  that  this  limitation  pertains  to  the 
formal  statement  of  cause  of  death  upon  certificates  of  death  as  at 
present  generally  employed. 

The  causation  of  disease  is  antecedent  to  the  actual  existence  of  the 
disease  in  the  given  case.  Much  of  the  information  under  this  head 
is  of  a  very  important  practical  character,  but  relates  rather  to  mor- 
bidity than  to  mortality  reports.  A  special  place  might  be  given  for 
such  data,  as  upon  the  back  of  the  Swiss  return,  but  many  of  the 
replies  would  be  merely  conjectural,  and  it  has  usually  been  necessary 
to  limit  the  statements  to  what  should  be  definite  facts  concerning  the 
cause  of  death,  not  the  cause  of  disease  leading  to  the  death.  Various 
important  predisposing  causes  of  disease-  can  also  be  obtained  from 
other  parts  of  the  certificate,  as,  for  example,  age,  sex,  nativity,  occu- 
pation, residence,  etc. 

The  process  of  dying  need  not  be  described  upon  a  certificate  of 
death.  Terms  descriptive  of  mere  terminal  conditions  or  symptoms  and 
of  the  modes  of  death  should  uniformly  be  omitted,  provided,  a  state- 
ment of  the  disease  leading  to  the  final  appearance  of  such  conditions 
or  symptoms  and  ultimate  death  can  be  given.  The  inclusion  of  such 
terms  upon  certificates  of  death  is  responsible,  to  a  very  considerable 
degree,  for  the  indefinite  and  unsatisfactory  character  of  the  returns. 
Deaths  from  asthenia,  collapse,  coma,  debility,  exhaustion,  "  heart 
failure,"  etc.,  are  compiled  under  ill-defined  causes,  unless  they  are 
reported  in  connection  with  some  definite  cause  of  death,  in  which 
case  the  terminal  conditions  are  neglected,  and  the  death  compiled 
under  the  proper  cause.  But  a  death  from  hypostatic  pneumonia,  for 
example,  occurring  as  a  terminal  state  of  chronic  Bright's  disease,  is 
quite  likely  to  be  reported  as  "  pneumonia,"  leading  to  possible  inclu- 
sion with  deaths  from  lobar  pneumonia,  and  thus  invalidating  the 
mortality  statistics. 

A  complete  schedule  of  post-mortem  findings  is  not  necessary. or 
desirable  upon  a  certificate  of  death.  What  is  wanted  is  the  exact 
statement  of  the  disease  causing  death.  (The  relation  of  the  post- 
mortem examination  to  deaths  from  violence  will  be  considered  a 
little  later.)  An  autopsy  may  be  indispensable  for  ascertaining  the 
nature  of  this  disease,  and  the  agreement  of  the  pathologic  find- 
ings with  the  clinical  diagnosis  may  be  of  the  highest  importance, 
e.  g.,'in  a  death  reported  from  }^ellow  fever  at  the  beginning  of 
an  epidemic,  as  giving  assurance  that  the  true  cause  of  death  has 
been  registered.  Negative  findings  may  be  of  value,  as  making  it  cer- 
tain that  the  disease  reported  as  a  cause,  of  death  was  not  confounded 
with  some  other  having  definite  pathological  lesions.  A  certificate 


53 

of  death  should,  preferably,  provide  a  space  for  a  brief  statement  of 
the  results  of  the  post-mortem  examination  (see  form  [33]),  or  at  least, 
as  in  the  Swiss  blank  [54],  should  state  whether  an  autopsy  was  held 
or  not;  and  if  an  autopsy  was  held,  then  the  statement  of  the  disease 
causing  death  should  be  based  upon  the  results  of  the  autopsy  and  the 
clinical  diagnosis,  and  not  solely  upon  the  clinical  diagnosis.  It  has 
happened,  and  undoubtedly  is  constantly  happening  at  the  present 
time,  that  certificates  of  death  are  filed  with  local  registrars  containing 
the  clinical  diagnoses  of  diseases  causing  death;  permits  are  duly  issued, 
and  the  certificates  accepted  as  the  basis  of  the  mortality  statistics  of 
the  city,  state,  and  United  States  Bureau  of  the  Census — the  last  on  the 
authority  of  transcripts  of  the  original  certificates  of  death  returned 
by  the  "state  or  city  authorities.  But  after  the  filing  of  the  original 
certificates,  or  even  before,  post-mortem  examinations  may  be  held 
which  reveal  entirely  different  causes  of  death.  The  results  of  such 
examinations  and  the  .pathological  diagnoses  are  not  used  to  correct  the 
erroneous  certificates.  It  is  desirable  that  such  discrepancies  should 
be  prevented,  and  the  use  of  a  special  blank  for  this  purpose,  as 
required  for  deaths  in  hospitals  and  other  institutions  in  Greater  New 
York,  may  be  heartily  commended. 

[55]  New  York,  N.  Y.  (Institutions),     X  \. 

UH-1KK 

STATE  OF  NEW  YORK.  No.  of  Certificate. 

CERTIFICATE  AND  RECORD  OF  DEATH 


IH 

P»  | 

.Tn.             .                Hem.    ._  _D»yi 

Character  of 
premises,  whether 

etc.  1?hoic!!rho«p.tal 

or  other  ir- 
•tat*  fall  title 

ovred'or  divorced 

apatlon 

Father's 

2 

5     111       Birthplace 
S    . I I 


:  *g5.  i _____ 

§  **%&*  i ijggj- 


jjj  /  hereby  certify  that  deceased  was  admitted  to  this  institution  on. 


that  I  last  sawh alive  on  the day  of.. 190 .,  that    be  died 

—      on  the. jiayof. J90. ,  about. .....o'clock  A.  AT.,  or  P.  M.,  and  that 

P      /  am  unable  to  state  definitely  the  cause  of  death  ;  the  diagnosis  during  h last  illness  was  : 

K      __ _ _ ;.__ „ 

o   _ , 


Z    Q  Witness  my  hand  this  , day  o/_ 


J.90 


SPECIAL  INFORMATION. 

Former  Residence. ». 

How  long  Resident  at  Place  of  Death. „.. 

o  = 


I hUOy  certify  that  1  have  this day  of,. J90_..  performed  an  autopsy  upon  the  body  of 

taid  deceased,  and  that  the  cause  of  h. death  was  as  follows: 


_ M.D. 

Pathologist .-. Oospitft 


54 

On  such  a  blank  considerable  pathological  detail  ma\-  be  expected, 
but  it  should  not  be  allowed  to  obscure  the  statement  of  the  disease 
causing  death  and  primarily  responsible  for  the  lesions  shown,  pro- 
vided the  evidence  is  sufficient  to  warrant  a  definite  statement. 
Otherwise  the  return  may  be  of  very  little  service  for  statistical  com- 
pilation, although  the  case  may  excite  the  wonder  of  the  general 
public  as  in  an  instance  quoted  from  a  newspaper  dispatch: 

Had  Ten  Diseases;  Fate  of  One  Man;  Physicians  at  Hospital  Call  for  Help  to  Per- 
form the  Post-Mortem.  Physicians  of  the Hospital  reported  to  the  coroner's 

office  to-day  that had  died  and  that  they  were  unable  to  determine  the  cause 

of  his  death.     Coroner instructed  the  physician,  Dr.  -     — ,  to  perform  an 

autopsy  and  the  hospital  physicians  watched  Dr.  —  —  with  interest  when  he  found 
that had  died  of  a  complication  of  diseases,  which  were:  Abscess  of  the  pan- 
creas, laceration  of  the  brain,  hemorrhage  of  the  brain,  dilatation  of  the  heart, 
pericarditis,  chronic  diffuse  nephritis,  pleurisy  with  intense  adhesion  of  both  lungs, 
gastritis,  dilatation  of  stomach  and  alcoholism.  And  then  he  issued  a  death  certifi- 
cate. 

The  transcript  of  this  death  certificate  that  reached  the  Bureau-  of 
the  Census  contained  simply  this  statement:  "The  cause  of  death  was 
as  follows:  Abscess  of  pancreas,  pericarditis.'"  This  may  suggest  that 
sometimes  the  statement  of  unnecessary  details  may  lead  to  the  omis- 
sion of  essential  facts.  On  this  subject,  the  relation  of  the  pathological 
findings  to  the  statement  of  cause  of  death,  and  with  special  reference 
to  the  death  from  typhoid  fever  under  consideration,  Delafield  and 
Prudden1  may  be  quoted. 

Great  care  is  necessary  in  endeavoring  to  ascertain  the  cause  of  death  when  the 
clinical  history  is  imperfect  or  unknown.  Mechanical  injuries,  which  destroy  life  by 
abolishing  the  function  of  one  of  the  important  viscera,  are  relatively  infrequent. 
Most  of  the  lesions  found  after  death  are  rather  the  marks  of  disease  than  the  cause 
of  death.  We  do  not  know,  for  example,  how  great  a  degree  of  meningitis,  or  of 
pneumonia,  or  of  endocarditis,  or  of  cirrhosis,  or  of  nephritis  necessarily  leads  to 
death.  On  the  contrary,  one  patient  may  recover  with  an  extent  of  lesion  which 
is  sufficient  to  destroy  the  life  of  another.  So  with  accidents;  there  is  often  no  evi- 
dent reason  why  fracture  of  the  skull  or  of  the  pelvis  should  destroy  life,  yet  they 
usually  do.  In  some,  of  the  infectious  diseases,  such  as  typhoid  fever,  the  visible  lesions 
can  not  be  called  the  cause  of  death.  Sudden  deaths  of  persons  apparently  in  good 
health  are  often  particularly  obscure.  In  many  of  them  we  have  to  acknowledge 
that  we  can  find  no  sufficient  cause  for  the  death.  This  is  of  course  due  to  our 
imperfect  knowledge,  but  it  is  much  better  in  such  cases  to  avow  ignorance  than  to 
attribute  the  death  to  some  trifling  lesion.  The  brain  and  the  heart  are  the  organs 
which  are  especially  capable  of  giving  symptoms  during  life  without  corresponding 
lesions  after  death.  Very  well  marked  cardiac  or  cerebral  symptoms  may  continue 
for  days  or  months,  and  apparently  destroy  life,  and  yet  after  death  we  find  no 
corresponding  anatomical  changes. 

Coming  finally  to  the  items  which  should  be  included  in  a  statement 
of  cause  of  death,  and  which  are  all  embraced  in  group  B,  Course  of 
disease,  as  given  in  the  tabular  arrangement  on  page  51,  it  may  be 

1  Pathological  Anatomy,  Cth  edition,  page  3. 


55 

said  that  it  is  not  necessary  or  desirable  to  include  all  symptoms  or 
complications  attending  the  course  of  the  disease.  In  fact,  it  is  not 
necessary  to  name  any  of  them  if  only  the  name  of  the  disease  causing 
death  and  responsible  for  the  secondary  affections  be  stated.  Mere 
symptoms  should  not  be  stated  at  all;  ordinary  minor  complications  are 
of  no  consequence;  and  other  diseases,  unless  they  play  a  distinct  part 
in  the  causation  of  the  death,  should  not  be  mentioned.  A  case-history 
of  the  decedent's  last  illness  or  previous  illness  is  not  wanted.  Such  a 
return  as  the  following,  which  was  received  at  the  Bureau  of  the  Cen- 
sus during  the  present  year  (1907)  and  which  is  easily  first  in  multi- 
plicity of  terms  among  the  several  millions  of  transcripts  received 
upon  the  standard  blank,  is  merely  ridiculous: 

The  CAUSE   OF    DEATH    was  as  follows: 

Diphtheria,  Antitoxin,  Septicaemia,  Erythema,  Urticaria, 
Dermatitis,  Lymphangitis,  Multiple  dermal  ulcer,  Abscesses, 
Rheumatic  Fever,  Hepatitis,  Jaundice,  Duodenitis  (DURATION)  4\  MOS. 
Contributory  Nephritis,  Pneumonia,  Erysipelas,  La  Grippe, 
Cerebro  Spinal  Meningitis,  Peritonitis,  Convulsions,  Death 

(DURATION)  96  Hrs. 

In  the  assumed  case  of  a  death  from  typhoid  fever,  with  the  various 
complications  indicated,  the  certificate  of  death  might  be  filled  out, 
according  to  some  of  the  various  forms  in  use,  as  follows: 

CAUSE  OF  DEATH  ...............  ......................  ] 

Disease  causing  death  ................................  | 

Primary  cause  of  death  ...............................  j-  Typhoid  fever. 

Chief  cause  of  death  .................................  | 

Chief  and  determining  cause  of  death  .................  J 

The  additional  statement,  of  entirely  subsidiary  importance,  may  be 
given: 

Secondary  cause  of  death 


Consecutive  and  contributing  cause  of  death  .  . 

It  may  be  of  very  considerable  medical  interest  to  know  just  what 
complications  are  the  most  frequent  immediate  causes  of  death  from 
typhoid  fever.  Doctor  Osier  estimates1  that  of  the  35,379  deaths 
compiled  from  typhoid  fever  by  the  United  States  Census  as  occur- 
ring in  the  United  States  during  the  census  year  1899-1900  between 
9,000  and  12,000  were  due  to  intestinal  perforation.  The  returns 
are  not  sufficiently  complete,  however,  to  show  the  true  relations 
of  secondary  affections  to  primary  causes,  and  it  is  more  important 

1  Principles  and  Practice  of  Medicine,  sixth  edition,  page  81. 


56 

that  all  of  the  primary  causes  should  be  reported  and  that 
no  deaths  be  erroneously  classified  through  failure  to  report  the 
principal  disease.  This  is  especially  liable  to  occur  where  blanks 
require  the  immediate  cause  to  be  stated  first  and  the  true  cause  of 
death  (primary  disease)  is  given  as  the  remote  or  contributory  cause, 
if  at  all. 

The  most  complete  form  of  statement  employed  in  this  county, 
which  is  quite  comparable  in  this  respect  with  the  Swiss  form — the 
most  complete  among  the  European  samples — is  that  originally 
employed  in  Michigan1  and  now  in  use  in  the  cities  of  Cincinnati, 
Ohio,  and  Norwalk,  Ohio  [33].  It  was  originally  suggested  by  Dr. 
Henry  B.  Baker,  former  secretary  of  the  State  Board  of  Health  of 
Michigan,  and  is  incorporated  in  the  Michigan  law  of  1897,  whose  first 
draft  (1895)  provided  chiefly  for  the  statement  of  "immediate  cause." 
A  death  registered  in  this  form  might  show: 


DISEASE   CAUSING   DEATH.. 

Immediate  cause  of  death ._.      ..  _Perforaii9n^  hemorrhage  of  intestine. 

Contributory  causes  or  complications,  if  any Bronchoprieumonia. 

Post-mortem          confirmed  statements  above. 

In  this  blank  the  immediate  cause  has  its  proper  subordinate  place, 
and  also  serves  to  catch  statements  of  modes  of  death,  such  as  "heart 
failure,"  coma,  etc.,  which  might  otherwise  be  reported  as  the  main 
cause  of  death.  Also  a  careful  physician  is  less  likely  to  report  "old 
age"  as  the  disease  causing  death  than  he  is  to  report  it  simply  as 
u  cause  of  death,"  especially  when  a  place  is  provided  for  its  insertion 
as  a  contributory  cause. 

The  whole  subject  of  mortality  statistics,  as  does  medicine  in  gen- 
eral, labors  under  the  disadvantage  of  lack  of  precision  and  definiteness 
in  the  terips  employed.  No  definition  can  be  found  for  the  much  used 
term  cause  of  death.  As  emploj^ed  in  vital  statistics,  this  term  may  be 
held  to  signify  either  (1)  a  disease,  or  (2)  a  form  of  violence  from  which, 
either  wholly  or  partly,  the  death  of  an  individual  results.  But  the 
word  disease  is  equally  ill  defined: 

DISEASE:  (a)  Any  departure  from  a  state  of  health;  an  illness;  more  frequently 
the  genus  or  kind  of  disturbance  of  health  to  which  any  particular  case  of  sickness 
may  be  assigned. 

(6)  A  condition  of  the  body  marked  by  inharmonious  acfion  of  one  or  more  of  the 
various  organs,  owing  to  abnormal  condition  or  structural  change. 

The  latter  part  of  the  first  definition  more  closely  represents  the 
conception  of  diseases  as  returned  and  tabulated  as  causes  of  death; 

1  See  facsimile  in  Reference  Handbook  of  the  Medical  Sciences,  article  by  the  late  Doctor  Samuel 
W.  Abbott  on  "Certification  of  Deaths; "  also  reproduced  by  Doctor  Chapin  in  his  work  on  Municipal 
Sanitation  in  the  United  States,  page  855. 


57        , 

but  it  is  difficult  to  give  explicit  directions  for  the  proper  statement 
of  diseases  when  almost  any  condition  of  "  departure  from  a  state  of 
health"  may  be  included  in  the  categoiy.  Of  the  conditions  included 
under  section  B,  page  51,  only  typhoid  fever  and  the  intercurrent  acute 
lobar  pneumonia  are  entitled  to  the  designation  of  diseases;  the  others 
are  secondary  affections  which  should  not  be  returned  or  classified  as 
individual  causes  of  death.  "Dropsy  "  is  certainly  a  "  condition  of  the 
body  marked  by  inharmonious  action  of  one  or  more  of  the  various 
organs;"  nevertheless  it  should  not  be  reported  as  a  disease  causing 
death,  but  the  disease  of  the  heart,  liver,  kidneys,  etc.,  which  caused  it 
should  be  named.  That  this  fact  is  already  recognized,  even  among  the 
laity,  is  shown  by  the  following  quotation:1  "Dropsy  is  not  a  disease 
in  itself,  but  is  a  symptom  associated  with  a  number  of  different  dis- 
eases, chiefly  of  the  heart  and  kidneys." 

What  names  of  diseases  shall  be  employed  by  the  physician  in 
reporting  causes  of  death  ?  The  practical  compilation  of  returns  of 
deaths  is  greatly  embarrassed  by  the  large  number  of  more  or  less 
synonymous  expressions  employed  to  designate  the  same  disease.2 
The  commonly  accepted  English  name  of  the  disease  should  be  inva- 
riably used,  as,  in  the  United  States,  typhoid  fever  for  the  disease 
taken  as  an  example.  (The  accepted  term  in  England  is  enteric  fever; 
this  is  one  of  the  few  cases  in  which  the  usage  of  the  two  countries 
differs.)  Unfortunately  we  have  in  the  United  States  no  generally 
accepted  standard  of  nomenclature  for  the  naming  of  diseases.  In 
England  the  "Nomenclature  of  Diseases  drawn  up  by  a  Joint  Com- 
mittee appointed  by  the  Royal  College  of  Physicians  of  London,"  of 
which  the  third  revision  has  recentty  been  published  (1906),  furnishes 
an  authoritative  guide  of  the  greatest  service  to  physicians  in  report- 
ing causes  of  death.  At  the  last  meeting  of  the  American  Medical 
Association,  held  at  Atlantic  City,  N.  J.,  it  was  voted,  on  June  4, 1907, 
that  the  president  of  the  -association  appoint  a  committee  of  five  on 
nomenclature  and  classification  of  diseases,  as  a  result  of  whose  labors 
this  need  of  the  medical  profession  of  the  United  States  may  be  met. 
In  the  meantime,  and  in  the  absence  of  an}r  other  guide,  it  would  be 
well  if  the  Nomenclature  of  the  Royal  College  of  Physicians  could  be 
followed  in  this  country  and  physicians  employ  only  the  terms  author- 
ized therein.  It  should  be  remembered  that  a  nomenclature  of  diseases 
is  not  a  statistical  classification,  and  this  recommendation  does  not 
affect  in  any  way  the  adherence  to  the  International  Classification  of 
Causes  of  Death,  which  is  the  accepted  standard  in  the  United  States. 
It  rather  aids  its  usefulness,  because  a  satisfactory  nomenclature  of 
diseases  is  a  fundamental  requisite  for  an  effective  statistical  classifica- 
tion of  causes  of  death. 

1  Youth's  Companion,  August  1,  1907. 

2 See  Manual  of  International  Classification  of  Causes  of  Death,  published  by  the.  Bureau  of  the 
Census  in  1902,  and  containing  terms  actually  employed  upon  certificates  of  death. 


58 
(2)   D  eat  Jis  from  violence. 

The  facts  required  on  a  certificate  of  death  from  violence  are  of 
quite  a  different  character  from  those  required  on  a  certificate  of 
death  from  disease,  and  a  complete  statement  can  not  well  be  expected 
unless  special  provision  is  made  in  the  arrangement  of  the  blank  or 
special  instructions  be  given  to  the  physician,  health  officer,  or  coroner 
making  the  report.  The  transcripts  received  by  the  Bureau  of  the 
Census  are  especially  unsatisfactory  in  this  respect,1  and  although 
efforts  have  been  made  to  secure  more  complete  statements  by  corre- 
spondence with  the  local  registrars  sending  indefinite  returns  the 
improvement  is  comparatively  slight.  Success  can  not  be  obtained  in 
this  way,  but  only  by  seeing  that  the  certificates  contain  all  of  the 
data  required  when  originally  filed  with  the  local  registrar. 

The  kind  of  facts  desired  may  be  seen  from  the  general  classification 
of  violent  deaths,  whether  from  (1)  accident  and  negligence,  (2)  suicide, 

(3)  murder,  or  (tt)  manslaughter,  as  employed  by  the  Registrar-General 
of  England  and  Wales: 

Cause  or  character  of  accident;  method  of  suicide,  murder,  or  manslaughter. 

1.  Mines,  quarries,  etc. 

2.  Vehicles  and  horses. 

3.  Ships,  boats,  docks,  etc.  (excluding  drowning). 

4.  Building  operations. 

5.  Machinery. 

6.  Weapons  and  implements. 

7.  Conflagrations,  burns,  scalds,  explosions  (not  in  mines,  ships,  etc.). 

8.  Poisons  and  poisonous  vapors. 

9.  Drowning. 

10.  Suffocation. 

11.  Falls. 

12.  Weather  agencies. 

13.  Otherwise  or  not  stated. 

And,  more  minutely,  under  2  (a),  for  example,  Injuries  on  railways, 
there  is  an  exact  specification  of  the  mode  in  which  the  injury  occurred, 
as,  "run  over  on  line,"  "collision,"  "locomotive  machinery,"  "strik- 
ing against  bridge,"  etc.  The  kinds  of  mines  are  specified  and  always 
the  special  means  of  injury  or  agent  by  which  the  casualty  occurred. 

i  See  Mortality  Statistics,  1900  to  1904,  page  lv:  "  In  the  statistical  treatment  of  this  class  of  deaths 
they  naturally  fall  into  four  primary  groups— (1)  suicide,  (2)  homicide,  (3)  accidental  violence, 

(4)  other  external  causes;  but  the  information  upon  which  the  classification  must  be  made  is  too 
incomplete  to  permit  the  accurate  separation  of  the  deaths  even  by  these  general  groups,  and  all 
general  statistics  of  deaths  from  suicide,  homicide,  and  various  special  forms  of  accident,  derived 
from  registration  records,  are  incorrect  and  absolutely  misleading.    It  would  seem  that  in  this  class 
of  deaths  more  than  any  other  there  should  be  no  difficulty  whatever  in  securing  a  proper  classifi- 
cation, to  the  extent  specified  at  least,  since  it  is  the  only  class  in  which  there  are  practically  uni- 
versal provisions  for  an  official  inquiry  into  the  circumstances  attending  each  death,  by  a  coroner, 
medical  examiner,  or  other  official,  for  the  precise  purpose  of  determining  whether  the  death  was 
due  to  homicide  or  suicide  or  to  purely  accidental  causes;  but  instead  of  this  being  true  the  returns 
in  this  class  of  cases  are  the  most  unsatisfactory." 


59 


The  International  Classification  of  Causes  of  Death  does  not  make 
clear-cut  distinctions  in  this  respect,  but  admits  such  a  title  as  u  Frac- 
tures," a  term  merely  expressive  of  the  nature  of  the  injury  (lesion) 
and  not  of  the  nature  of  the  violence,  and  one  which  the  Registrar- 
General  considers  indefinite  and  places,  in  the  absence  of  other  infor- 
mation, under  "  13.  Otherwise  or  not  stated." 

As  an  example  of  the  factors  to  be  considered  in  violent  deaths,  the 
following-  illustrative  cases  may  be  presented: 


Class  of  fact. 

Case!. 

Cas.-'j. 

CaseS. 

1   CHARACTER  OF  VIOLENCE  H 

Accidental  

Suicidal 

Homicidal. 

2    MEANS  OF  VIOLENCE 

Toy  pistol 

River 

Revolver 

3.  Nature  of  injury  (lesion);  imme- 
diate cause  of  death. 

4   Secondary  effects  of  injurv,  includ- 

Wound of  hand... 
Tetanus  

Drowning   (as- 
phyxia). 

Wound  of   abdomen, 
perforation  of  intes- 
tine. 
Peritonitis. 

ing  infection  of  wound  (sepsis, 
tetanus)  . 
5   Contributory  disease  or  condition 

Acute  mania 

Alcoholism 

In  the  above  cases,  and,  in  fact,  in  all  deaths  from  violent  causes, 
there  are  two  items  that  are  absolutely  essential  for  statistical  pur- 
poses; these  are,  (1)  the  character  of  the  violence,  and  (2)  the  means  of 
violence. 

The  character  of  the  violence,  as  accidental,  suicidal,  homicidal,1 
forms  the  primary  basis  of  classification.  A  place  should  be  provided 
for  its  statement  on  every  certificate  of  death,  and  no  case  of  violent 
death  should  be  left  unqualified  in  this  respect.  "Probably  accidental " 
may  be  written  in  a  doubtful  case,  or  "Unknown"  if  absolutely 
impossible  to  determine;  but  in  many  cases  the  character  is  left 
unstated  when  it  is  perfectly  eas}7  to  give  it.  In  case  of  a  railway 
collision  it  is  not  necessary  to  await  the  verdict  of  the  coroner's  jury 
before  reporting  any  death  resulting  therefrom  as  accidental;  a  verdict 
to  the  effect  that  the  collision  resulted  from  criminal  negligence  would 
not  change  the  statistical  character  of  the  death  return,  however  it 
might  alter  its  legal  aspect.  No  fine  distinctions  as  to  murder,  man^ 
slaughter,  or  justifiable  homicide  appty  to  a  statement  of  homicidal 
violence;  it  is  sufficient  that  one  person  kills  another  and  not  by 
accident. 

.  The  second  essential  feature  of  a  return  of  a  death  from  violence  is 
the  means  or  agency  causing  the  death.  A  specific  statement  should 
be  made  of  the  special  cause  of  the  injuiy,  as  by  fall  of  elevator, 
struck  by  trolley  car,  fell  from  building,'  carbolic  acid  (names  of 
poisons  should  always  be  stated),  etc. 

Frequently  a  satisfactor}^  statement  of  both  items  1  and  2  can  be 
given  in  a  single  expression;  as,  lightning,  sunstroke,  boiler  explosion, 

1  Legal  execution,  war,  and  catastrophes  such  as  earthquakes,  volcanic  eruptions,  tidal  waves,  etc.; 
should  be  made  special  subdivisions  when  necessary,  the  latter  group  because  it  includes  various 
modes  of  violent  death,  as  ordinarily  classified,  but  all  due  to  one  common  cause. 


60 

collision  on  railway,  etc.  .But  if  there  be  any  shadow  of  doubt  as  to 
the  event  being  entirely  free  from  possibility  of  interpretation  as 
suicidal  or  homicidal,  its  accidental  character  should  be  stated. 

The  remaining  items,  3  to  5,  are  not  essential  for  statistical  pur- 
poses, but  may  be  very  important  otherwise,  and  should  be  specified 
as  completely  as  possible.  Tetanus  resulting  from  a  wound  should 
always  be  mentioned.  It  may  be  noted  that  while  the  injury  itself— 
that  is,  the  lesion  resulting  from  the  violence,  as  a  fractured  skull,  a 
wound  inflicted  by  a  firearm,  or  the  burn  resulting  from  a  conflagra- 
tion— may  be  considered  the  primary  cause  of  death  in  the  same  sense 
that  the  disease  itself  (e.  g.,  typhoid  fever)  is  considered  the  primary 
cause  of  death  in  a  death  from  disease,  in  the  first  case  the  statement 
of  the  primary  cause  is  not  necessary  and  in  the  second  case  it  is  neces- 
sary for  statistical  purposes.  Fractures,  wounds,  and  burns  are  indefi- 
nite terms,  and  we  desire  to  know,  for  the  purposes  of  statistical  classi- 
fication, what  caused  the  fracture,  whether  the  wound  was  caused  by  a 
firearm,  or  the  burn  by  a  conflagration.  In  other  words,  we  wish  to 
know  the  proximate  cause  of  the  injury,  corresponding  to  the  Bacillus 
typhosus  as  a  cause  of  typhoid  fever,  together  with  the  directive 
influence  determining  that  cause  (suicide,  homicide),  or  a  statement 
that  there  was  no  directive  or  purposive  element  (accident,  negligence, 
effect  of  weather  agencies).  The  element  of  purpose  is  entirely  absent, 
as  a  rule,  from  deaths  from  disease.1  The  dissimilar  character  of  the 
information  required  in  deaths  from  disease  and  in  deaths  from  violence 
is  chiefly  responsible  for  the  imperfect  returns  of  the  latter  and  for 
the  absence  of  proper  forms  of  statement  on  nearly  all  of  the  forms 
employed  for  certificates  of  death. 

1  A  case  of  self-infection  by  typhoid  fever  with  suicidal  intent,  cited  by  Schultze  in  his  article  on 
"Autopsies,"  Reference  Handbook  of  the  Medical  Sciences,  might  be  considered  suicide  by  disease, 
and  wilful  persistence  in  providing  a  contaminated  water  supply  verges  on  homicide,  but  prac- 
tically all  deaths  from  disease  are  considered  "accidental "  in  the  sense  of  absence  of  purpose  in  their 
incidence. 


DURATION  OF  ILLNESS. 

The  blanks  used  in  the  United  States  provide,  as  a  rule,  for  a  fairly 
satisfactory  statement  of  duration  of  illness.  The  standard  blank  is 
not  as  excellent  in  this  respect  as  the  English  form,  with  its  columns 
for  "Years,"  " Calendar  months,"  "Days,"  and  "Hours."  Not  in- 
frequently transcripts  are  received  showing*  duration  of  a  few  days 
from  such  diseases  as  chrtmic  Bright's  disease.  This  may  mean  either 
that  the  terminal  symptoms  are  referred  to  only,  or  that  the  physician 
or  transcriber  forgot  to  crosscut  the  word  "Days  "and  write  "Months" 
or  "Years"  as  the  case  might  be.  It  is  difficult  to  suggest  a  remedy 
with  the  present  form  of  the  blank,  although  it  would  possibly  be 
better  not  to  have  any  word  on  the  form  that  is  not  always  applicable; 
let  the  physician  write  "3  inos.,"  "3  days,"  etc.  Another  objection  is 
that  by  specifying  "days,"  the  physician  may  state  no  duration  if  it  is 
less  than  one  day;  this  is  especially  objectionable  in  the  case  of  children 
dying  soon  after  birth,  who  may  thus  come  to  be  included  among  still- 
births. "Acute"  and  "chronic,"  employed  upon  the  French  blanks,  are 
serviceable  for  precision  under  certain  titles  of  the  International  Classi- 
fication (acute  and  chronic  bronchitis,  rheumatism,  nephritis),  but  are 
very  indefinite  terms,  and  should  be  considered  in  connection  with  a 
correct  statement  of  duration.  The  physician  and  registrar  should 
always  note  the  relative  duration  of  related  terms;  the  primary  cause 
or  disease  causing  death  can  not  have  a  less  duration  than  one  of  its 
secondaiy  affections  or  consequences. 

(61) 


CONCLUSIONS  AND  RECOMMENDATIONS. 

/ 

As  a  result  of  the  examination  o^  present  conditions,  it  seems  proper 
tOJsubmit  to  the  registrars  of  the  United  States,  soon  to  be  organized 
as  a  national  body  and  constituting  a  Section  of  the  American  Public 
Health  Association,  some  propositions  looking  to  the  improvement  of 
the  registration  of  causes  of  death,  and  especially  to  the  adoption  of 
more  uniform  methods  for  the  United  States  as  a  whole.  Whatever 
is  done  must  depend  upon  harmonious  individual  action  of  the  regis- 
tration states  and  cities.  The  Census  has  no  authority  except  to  sug- 
gest the  desirability  of  certain  measures,  ,but  its  work  is  for  the 
benefit  of  all,  and  if  there  should  be  a  general  agreement  as  to  the 
expediency-  of  action  in  any  direction,  it  is  hoped  that  mere  individual 
preference,  however  well  founded,  will  yield  for  the  greater  good  to 
the  whole  United  States  that  can  come  only  from  concerted  action. 
Such  action  should  be  well  considered  before  it  is  taken.  The  recom- 
mendations, together  with  any  others  affecting  statistical  practice, 
should  be  laid  before  the  annual  meeting,  referred  to  the  proper  com- 
mittee for  report  at  the  succeeding  one,  printed  in  the  proceedings 
and  distributed  to  every  registrar  of  vital  statistics  in  the  United 
States  for  his  consideration.1  If  necessary  a  referendum  should  be 
taken  to  tte  individual  offices.  The  report  of  the  committee  and  the 
expressions  of  the  state  and  city  offices  should  be  thoroughly  digested, 
and  when  a  final  decision  has  been  made,  by  a  majority  or  two-thirds 
ballot,  that  action  should  stand  as  the  action  of  all  of  the  registrars  of 
the  United  States  and  should  be  carried  out  by  them  faithfully  in 
accordance  with  the  general  desire.  There  can  be  no  real  prog- 
ress in  the  upbuilding  of  a  National  System  of  Vital  Statistics — 
something  in  which  this  country  is  at  present  behind  all  of  the 
civilized  nations  of  the  world — until  some  definite  basis  of  agreement 
can  be  reached  and  maintained  relative  to  the  collection  of  the  basic 
material.  It  is  worse  than  useless  to  attempt  a  local  change  or  improve- 
ment here  and  there,  which  has  no  chance  of  general  adoption,  and 
which  only  serves  to  cause  still  greater  confusion  and  complication  of 
methods.  By  the  plan  proposed  anr^)le  notice  will  be  given  of  any 
change,  so  that  no  loss  of  blanks  already  printed  will  result — the  form 
proposed  would  not  become  effective  at  the  earliest  before  January  1, 
1909 — and  the  satisfaction  of  feeling  that  each  office,  large  or  small, 

1  This  pamphlet  has  been  sent  to  the  registration  officials  of  all  states  and  places  of  8,000  inhabitants 
or  more  (Census  of  1900). 

(62) 


63 

is  employing  standard  methods  and  contributing  fully  comparable  data 
to  the  vital  statistics  of  the  United  States  should  amply  compensate 
for  the  slight  trouble  of  making  any  change. 

It  is  therefore  recommended,  subject  to  the  consideration  and  ap- 
proval of  the  American  Association  of  Registrars  of  Vital  Statistics  l 
organized  as  a  Section  of  the  American  Public  Health  Association, 
that  certain  resolutions  be  adopted: 

Proposed  Resolution  No.  1. — That  a  uniform  mode  of  statement  of 
causes  of  death  upon  certificates  of  death  shall  ~be  adopted  by  all  regis- 
tration offices  in  the  United  States  which  shall  provide,  First,  in  the 
case  of  a  death  from  disease,  for  the  name  of  the  disease  causing 
death  9  and  in  the  case  of  a  death  from  violence,  for  the  means  of 
ffcttth,  and  whether  accidental,  suicidal,  or  homicidal; 
together  with  such  subsidiary  information,  if  any,  as  may  he  necessary, 
under  the  head  of  "resulting  in"  or  "aided  by" 

As  an  example  of  how  such  data  might  be  provided  for  with  but 
slight  modification  of  the  standard  blank,  the  following  form  is  sub- 
mitted : 

[56]     Proposed  form  of  statement. 


MEDICAL  CERTIFICATE  OF  DEATH 

DATE  OF   DEATH 

..19.... 

(Month)  (Day)  (Year) 

I  attended  deceased  from 19 

to__  ..  19 ,  I  last  saw  h alive  on 

__19 ,    and   I   HEREBY   CERTIFY 

that  death  occurred  on  the  date  above  at...  __M.     The  DISEASE 

r        MEANS  OF  DEATH *^  Duration  in 

CAIKim  DEATH  [>•      ( g_j_  —  _—    ]  -.  „   V.,,s,  Mo«h!, 

Hours. 

Resulting  in: 

or  Aided  by: L___" 

(Signed)  M.I). 

..1»0_.._    __  (Address) 


{Accidental? 
Suicidal? 
Homicidal? 


1  Or  whatever  name  the  Section  may  adopt. 


64 

The  proposed  form  will  concentrate  the  attention  of  the  certifying 
physician  or  coroner  upon  the  fact  that  it  is  necessary  to  name  the 
disease  that  caused  the  death,  or  the  means  from  which  a  violent  death 
resulted,  with  complete  absence  of  the  very  uncertain  meanings  some- 
times embraced  under  the  term  "  cause  of  death.'1  It  will  be  compar- 
atively easy  to  give  definite  instructions  as  to  just  what  is,  and  just 
what  is  not,  a  "disease"  for  the  purposes  of  registration;  and  to 
explain  the  use  of  the  word  "means"  so  that  precisely  the  class  of 
information  necessary  for  classifying  violent  deaths  can  be  obtained. 
The  expression  "cause  of  death"  is  an  ill-defined  or  undefined  term, 
of  complex  significance  even  when  employed  in  the  strict  sense  under- 
stood in  vital  statistics,  and  also  includes  other  conceptions,  such  as 
terminal  condition,  mode  of  dying,  and  cause  of  disease,  that  serve 
only  to  perplex  reporting  physicians  and  to  vitiate  the  mortality 
statistics.  Its  entire  disuse  upon  certificates  of  death,  at  least  in  the 
most  important  position,  is  therefore  advised;  its  use  in  registration 
reports  and  bulletins,  as  a  convenient  general  term,  is  quite  another 
matter,  as  it  is  seldom  improperly  employed  therein. 

The  term  "disease  causing  death"  may  be  criticised  upon  the 
ground  that,  at  the  time  of  the  making  out  of  the  certificate,  the  dis- 
ease is  no  longer  a  continuing  cause,  and  that  it  would  be  better  to 
speak  of  the  "disease  that  caused  death."  Either  term  will  serve, 
but  it  is  an  objection  to  the  latter  that  a  disease  that  very  remotely 
caused  death  may  not  be  actually  present  at  the  time  of  death,  and 
hence,  under  the  accepted  method  of  classification,  should  not  be 
entered  as  the  cause  of  death.  A  child  may  have  rheumatic  fever  with 
endocarditis  and  recover  from  the  rheumatic  fever.  Years  afterward 
the  individual  may  die  from  valvular  heart  disease  remotely  due  to 
the  rheumatic  infection.  Under  the  International  Classification,  and 
probably  in  practical  agreement  with  most  methods  in  use,  it  is 
expressly  provided  that  deaths  from  rheumatic  fever  shall  not  include 
deaths  from  organic  diseases  of  rheumatic  origin;  the  organic  heart 
affection  is  taken  as  the  primary  cause  of  death.  This  rule  may  be 
subject  to  criticism,  but  while  it  is  practically  accepted,  only  a  disease 
actually  present  at  time  of  death  should  be  reported  as  the  disease 
causing  death. 

The  word  "means,"  as  used  only  in  connection  with  the  statement 
of  deaths  from  violence,  is  fairly  definite,  in  the  sense  of  "instru- 
ment" and  "necessary  condition  or  coagent."  When  the  instrument 
is  a  deadly  weapon,  its  use  is  implied  by  the  mere  name,  and  the 
statement  of  the  character  of  the  act  as  accidental,  suicidal,  or  homi- 
cidal. When  the  instrument  is  not  a  deadly  weapon,  the  statement  of 
means  may  properly  incjude  the  necessar}^  condition  of  action,  although 
even  here  the  mere  naming  of  the  instrument  is  usually  sufficient  for 
the  main  purpose  of  classification;  thus,  "elevator,"  "horse,"  or 


65 

"bicycle,"  would  be  sufficient,  although  a  little  more  detail,  as  "fall 
of  elevator,"  "kicked  by  horse,"  "fell  from  bicycle,"  would  usually 
be  given.  Properly  understood,  the  exclusive  use  of  this  term  would 
prevent  the  mere  statement  of  the  lesion,  such  as  "fracture  of  skull," 
"hemorrhage,"  etc.,  without  giving,  in  the  first  place,  the  instrumen- 
tality or  means  by  which  it  was  caused,  and  which  is  primarily  necessary 
for  statistical  compilation. 

The  subsidiary  information  is  less  important,  providing  we  can  assure 
a  correct  statement  of  the  disease  causing  death,  or  the  means  of  death 
in  accidents,  suicides,  and  homicides.  Possibly  some  of  the  old  terms 
could  be  chosen,  such  as  "secondary,"  "immediate,"  "concurrent," 
and  after  settling  upon  their  exact  definitions  and  educating  all  con- 
cerned in  their  definite  use,  the  purpose  would  be  answered,  which  is 
chiefly  that  the  true  cause  of  death  be  picked  up  in  the  subsidiary 
statement  when  the  physician  or  coroner  does  not  properly  enter  it 
in  the  principal  one.  The  mam  relations  of  importance  would  be 
clearly  shown  by  the  arrangement  suggested,  which  has  the  advantage 
of  breaking  away  from  the  hackneyed  terms  employed  for  this  purpose, 
the  most  definite  of  them  being  widely  misunderstood.  It  is  possible 
for  the  physician  to  indicate,  by  crossing  out  the  term  that  does  not 
particularly  apply,  just  how  he  wishes  the  minor  cause  to  be  under- 
stood. "Resulting  in"  would  always  mark  a  secondary  affection, 
while  "Aided  by,"  alone,  would  show  that  it  was  an  independent  dis- 
ease or  injury.  The  plan  of  stating  duration  is  merely  suggested;  the 
present  form  [1]  can  be  retained  if  desired. 

/  roposed  Resolution  No.  62.  —  That  a  continuous  and  systematic  effort 
be  made,  through  the  conjoined  action  of  the  local,  state,  and  Govern- 
ment authorities,  to  secure  the  cooperation  of  physicians  and  coroners 
in  the  more  definite  and  satisfactory  statement  of  causes  of  death;  and 
that  for  this  purpose  each  certificate  of  death  hear  a  certain  minimum 
amount  of  suggestions  in  regard  to  the  statement  of  cause  of  death, 
which  shall  he  uniform  throughout  the  United  States,  in  addition  to 
any  special  instructions  or  regulations  required  for  local  use. 

As  a  basis  for  discussion  in  regard  to  what  this  minimum  amount 
shall  be,  the  following  draft  of  suggestions,  which  can  readily  be 
inserted  upon  the  reverse  side  of  any  certificate  or  printed  on  the 
inside  of  the  cover  of  the  booklet  of  blanks  supplied  to  physicians  and 
coroners,  has  been  prepared: 

(DRAFT  OF)  SUGGESTIONS  TO  PHYSICIANS  AND  CORONERS  RELATIVE  TO  THE  STATEMENT 

OF   CAUSE   OF   DEATH. 

(Adopted  by  the  American  Public  Health  Association  and  recommended  by  the 
United  States  Bureau  of  the  Census  for  the  purpose  of  securing  uniformity  in  returns 
of  deaths  throughout  the  United  States.1  Please  read  carefully.} 

1  Provided,  of  course,  that  any  definite  instructions  can  be  generally  agreed  upon. 
9159—07 5 


66 

A.   Deaths  from  disease. 

1.  Name,  first,  the  DISEASE  CAUSING  DEATH.     What  is  wanted  is  the  name  of  the 
disease  (or  malformation)  itself  responsible  for  the  death;  not  a  mere  secondary,  con- 
secutive, contributory,  or  immediate  cause,  complication,  symptom,  terminal  condi- 
tion, or  mode  of  death.     Never  report  a  death  from  such  ''causes"  as  asphyxia, 
asthenia,  collapse,  coma,  convulsions,  debility,  dropsy,  exhaustion,  heart  failure, 
hypostatic  pneumonia,  inanition,  marasmus,  old  age,  shock,  syncope,  or  weakness, 
if   a  definite  disease  causing  the  condition  can  be  named.     WAS   IT  PUERPERAL? 
Always  qualify,  as  puerperal  convulsions,  puerperal  peritonitis,  puerperal  septicemia, 
etc.,  all  deaths  resulting  from  childbirth  or  miscarriage. 

2.  Important  secondary  affections  or  independent  (concurrent)  diseases  actually 
contributing  to  the  death  may  be  named. 

Example:  Measles  (disease  causing  death);  bronchopneumonia  (secondary 
affection). 

B.  Deaths  from  violence. 

1.  Name,  first,  the  MEANS  OF  DEATH,  and  whether  ACCIDENTAL,  SUICIDAL,  or  HOMI- 
CIDAL; as,  accidental  drowning.;  suicide — carbolic  acid;  railroad  collision. 

NOTE. — In  the  last  example,  it  is  not  necessary  to  write  "Accidental,"  because 
such  cases  are  plainly  of  that  character.  A  judicial  determination  of  "man- 
slaughter" on  account  of  negligence  does  not  affect  the  statistical  character  of  the 
return,  and  a  coroner  should  not  delay  the  filing  of  the  certificate  of  death  on  that 
account. 

2.  Nature  of  injury    (lesion)  or  immediate  cause  of  death  may  be  given  if  not 
implied  under  (1). 

3.  Important   secondary  affections    (e.    g.,    erysipelas,    septicemiaj    tetanus)    and 
contributory  diseases  (e.  g.,  insanity,  alcoholism)  should  always  be  stated. 

Duration. 

Enter  duration,  in  years,  months,  days  or  hours,  after  each  separate  cause  of 
death.  Duration  of  a  disease  is  from  its  commencement  until  death  occurs;  do  not 
merely  give  time  of  final  illness  in  chronic  diseases.  Duration  in  deaths  from 
violence  is  from  the  time  of  injury  or  appearance  of  complication  until  death. 

This  draft  is  merely  suggestive.  Some  cities  already  have  more 
stringent  directions  and,  by  the  direct  communication  possible  in  a 
city  between  the  reporting  physician  and  the  registrar,  have  elimi- 
nated some  undesirable  classes  of  returns.  For  the  country  as  a  whole, 
however,  strict  compliance  with  the  instructions  given  above  would 
work  a  vast  improvement  in  the  returns,  and  it  would  be  especially 
beneficial  if  such  a  guide  could  appear  on  all  state  blanks. 

If  it  be  possible  to  agree  upon  certain  explicit  instructions  as  sug- 
gested above,  and  similar  in  their  purpose  to  those  disseminated  by 
the  Registrar-General  of  England  to  the  physicians  of  that  country, 
then  the  Bureau  of  the  Census  can  cooperate  in  a  very  practical  man- 
ner with  the  state  and  local  offices  by  bringing  home  to  the  individual 
attention  of  every  physician  in  this  country,  at  occasional  intervals, 
the  importance  of  precise  and  definite  statements  of  causes  of  death. 
This  may  be  done  by  means  of  a  pocket  leaflet  or  small  pamphlet  of  a 
size  such  as  can  readily  be  carried  in  a  vest  pocket  or  visiting  list,  and 


67 

perhaps  containing  the  scheme  of  statistical  classification  (Inter- 
national), with  indication  of  indefinite  terms  and  secondary  affections, 
as  in  the  booklet  distributed  to  physicians  in  Switzerland.  Moreover, 
with  exact  directions  available  for  reference,  the  instruction  of  newly 
appointed  local  registrars  would  be  greatly  facilitated,  and  a  uniform 
method  of  obtaining  corrections  of  imperfect  data  would  be  more 
readily  installed. 

I*Ost8CTipt, — In  this  pamphlet  the  bearing  of  the  correct  and 
orderly  statement  of  causes  of  death  upon  the  statistical  compilation  of 
such  causes,  especially  when  two  or  more  causes  are  returned  for  the 
same  death,  has  only  ~been  casually  touched  upo^  The  subject  of  ''''joint 
causes'1'1  has  heen  a  perplexing  one  from  the  very  beginning  of  vital 
statistics,  and  irregularities  and  discrepancies,  some  of  great  impor- 
tance, may  he  found  in  'mortality  reports  because  no  adequate  plan  has 
yet  been  accepted  for  their  treatment.  Several  plans  have  been  devised, 
and  it  is  intended  to  compare  them,  together  with  the  principles  that 
hare  been  formulated  by  various  authorities  for  this  purpose,  in  a 
revised  edition  of  the  Manual  of  International  Classification  of  Causes 
of  Death,  which  it  is  hoped  to  have  ready  next  year  in  preparation  for 
the  approaching  Decennial  Revision.  But  it  is  probable  that  the  true 
solution  of  this  question  will  not  be  reached  until  physicians  and 
coroners  are  educated  in  the  proper  reporting  of  causes  of  death  so  that 
their  order  of  statement  can  be  depended  upon;  and  until  registration 
officials  shall  at  once  detect  any  inconsistency  or  anomaly  of  statement, 
and  secure  prompt  correction  or  interpretation  thereof,  so  that  a  simple 
rule  of  dependence  upon  the  disease  causing  death  as  reported  by 
the  attending  physician  and  accepted  by  the  local  registrar  can  be 
followed. 


APPENDIX  A. 


CIRCULAR   OF   ANNOUNCEMENT  OF  ORGANIZATION   OF   AMERICAN 
ASSOCIATION  OF  REGISTRARS  OF  VITAL  STATISTICS. 


Ammratt  iJttbltr  ijfaltij  A00ortattnn 


Sty?  Utttteb  §>iat?0  nf  Ammra 
inmuwm  of  (Eattaim  Sty?  ffiepuhltr  of 

fepubUr  of  Olitha 

19flfi-r 


President  DR.  DOMINGO  ORVANANOS,  Mexico  City,  Mexico 

First  Vice-President,  DR.  QUITMAN  KOHNKE,  Covington,  Louisiana 

Second  Vice-President,  DR.  ROBERT  W.  SIMPSON,  Winnipeg,  Manitoba 

Third  Vice-President,  DR.  GARDNER  T.  SWARTS,  Providence,  Rhode  Island 

Secretary,  DR.  CHARLES  O.  PROBST,  Columbus,  Ohio 

Treasurer,  DR.  FRANK  W.  WRIGHT,  New  Haven,  Connecticut 


in  Atlantic  Qlttg,  &*pi.  30-®rt.  4,  190T 

ORGANIZATION    OF   SECTION    OF    VITAL   STATISTICS. 

At  the  last  meeting  of  the  American  Public  Health  Association,  in  accordance  with 
the  request  of  many  registration  officials,  the  following  resolution  was  adopted: 

Resolved,  That  a  committee  of  five  be  appointed  by  the  president  of  the  American 
Public  Health  Association  to  report  on  the  organization  of  a  Section  of  Vital  Statis- 
tics at  the  next  meeting  of  the  association,  and  that  it  be  authorized  to  notify  regis- 
tration officials  in  the  countries  represented  in  the  association,  particularly  inviting 
their  attendance  at  the  next  meeting,  and  to  prepare  a  constitution  for  approval  by 
the  association  and  adoption  by  the  section  at  that  time. 

The  committee  on  organization  appointed  to  carry  out  the  purpose  of  this  resolu- 
tion met  at  Washington  in  May,  and  formulated  a  draft  of  a  constitution,  the  first  two 
sections  of  which  are  as  follows: 

PURPOSE   OF  THE   ORGANIZATION. 

1.  The  purpose  of  this  organization  is  to  bring  about  a  closer  official  and  personal 
association  of  the  registration  officials  of  the  several  countries  composing  the  Ameri- 
can Public  Health  Association;  to  promote  the  introduction  of  effective  systems  of 
registering  vital  statistics;  to  aid  the  adoption  of  uniform  methods  of  collecting,  pre- 
serving, correcting,  and  compiling  registration  records  and  of  publishing  the  statis- 
tical-data  derived  therefrom  in  the  most  useful  form,  especially  for  sanitary  purposes; 
to  conduct  the  active  cooperation  of  the  American  Public  Health  Association  with 
the  Government  agencies  of  each  country  and  with  other  organizations  interested  in 

(69) 


70 

the  improvement  and  use  of  vital  statistics;  to  report  on  the  actual  condition  of  the 
International  Classification  of  Causes  of  Death  as  employed  in  vital  statistics  reports 
and  bulletins,  and  to  formulate  recommendations  for  its  decennial  revision;  to  help 
in  the  better  reporting  and  classification  of  the  mortality  of  occupations;  to  present 
and  discuss  papers  relating  to  vital  statistics  both  in  the  section  meetings  and  in  the 
general  sessions  of  the  American  Public, Health  Association;  and  in  general  to  pro- 
mote a  proper  appreciation  of  the  necessity  and  importance  of  vital  statistics  as  an 
absolutely  essential  basis  of  modern  public  health  work,  and  to  improve  the  charac- 
ter and  status  of  registration  service. 

MEMBERSHIP. 

2.  Registration  officials  and  other  workers  in  vital  statistics  who  are  members  of 
the  American  Public  Health  Association  shall  be  eligible  to  membership  in  the  Vital 
Statistics  Section. 

The  above  extract,  which  is  subject  to  approval  by  the  association  and  section, 
shows  the  general  scope  of  the  movement  as  understood  by  the  committee  on  organi- 
zation. Your  attendance  is  earnestly  requested  at  the  jirxt  inet-thtg  of  the  section, 
which  will  be  held  in  connection  with  the  Thirty-fifth  Annual  Meeting  of  the 
American  Public  Health  Association  at  Atlantic  City,  N.  J.,  beginning  on  Sep- 
tember 30  and  ending  October  4,  1907.  A  circular  will  be  sent  by  the  secretary  of 
the  association  giving  full  information  in  regard  to  reduced  railway  fares,  accommo- 
dations, etc.  It  is  expected  that  the  first  section  meeting  will  be  held  on  Monday, 
September  30,  when  the  preliminary  organization  will  be  effected. 

In  addition  to  organizing,  it  is  planned  to  begin  the  active  work  of  the  section  at 
this  meeting,  and  papers,  questions,  and  suggestions  on  various  phases  of  vital  statis- 
tics, and  especially  relating  to  the  practical  side  of  registration  work  and  the  sanitary 
uses  of  mortality  statistics,  are  requested.  They  may  be  sent  to  Dr.  Cressy  L. 
Wilbur,  Bureau  of  the  Census,  Washington,  D.  C.,  who  will  provisionally  act  as 
secretary  of  the  committee. 

There  is  a  large  field  of  usefulness  for  this  section,  and  it  should  have  the  enthu- 
siastic support  of  all  registration  officials  and  users  of  vital  statistics.     If  you  can  not 
be  personally  present  at  this  first  meeting,  or  send  a  paper  or  suggestions,  please  let  us 
know  that  you  are  interested  in  the  movement  and  will,  at  least,  be  with  us  in  spirit. 
Sincerely, 

J.  X.   HURTY,  Chairman, 
CRESSY  L.  WILBUR, 
JOHN  S.  FULTON, 
Jcsrs  E.  MON.TARAS, 
CHARLES  A.  HODGETTS, 

Committee, 


APPENDIX  B. 


CHECK    LIST    OF    REGISTRATION     OFFICIALS,    AND    OF    REPORTS    AND 
BULJ.ETINS  CONTAINING  VITAL  STATISTICS,  IN  THE  UNITED  STATES. 

EXPLANATORY  NOTE. — This  list  of  state  registrars  and  local  registrars  is  a  pro- 
visional one  of  all  places  (cities,  towns,  and  boroughs)  in  the  United  States  whose 
population  was  8,000  or  over  in  1900.  It  is  based  chiefly  upon  a  circular  request  for 
information  issued  July  24,  1907,  and  asking  the  following  questions  in  regard  to 
each  local  office: 

1.  Are  deaths  registered? 

2.  Under  state  law  or  city  ordinance? 

3.  Do  you  publish  city  reports  containing  mortality  statistics? 

4.  Annual  or  biennial?    Latest? 

5.  Do  you  publish  city  bulletins  showing  mortality? 

6.  Weekly,  monthly,  quarterly? 

7.  Name  of  city  registrar? 

8.  Official  title? 

Replies  were  promptly  received,  as  a  rule,  and  the  statements  as  to  publications 
and  nature  of  legislation  under  which  deaths  are  registered  have  been  accepted  on 
the  authority  of  the  local  registrars  given  in  the  last  column  of  the  table.  Com- 
parison has  been  made  with  reports  and  bulletins  on  file,  and  where  no  reply  was 
received  the  probable  condition  with  respect  to  state  or  municipal  legislation  has 
been  entered,  subject  to  future  correction.  Thus  it  is  known  that  all  places  in 
Massachusetts,  Michigan,  New  York,  and  Pennsylvania  are  under  state  law7,  sup- 
plemented, perhaps,  in  a  few  instances,  by  local  regulations.  A  registration  city  in 
a  nonregistration  state  which  has  no  general  state  law,  e.  g.,  Atlanta,  Ga.,  must 
necessarily  have  a  city  ordinance  for  the  registration  of  deaths.  But  in  nonregistra- 
tion states  with  general  state  laws  for  the  registration  of  deaths,  but  which  are  not 
usually  effective,  registration  may  be  conducted  under  local  ordinances,  as  in  Kansas, 
Ohio,  and  Texas.  In  such  cases,  in  the  absence  of  direct  statement,  "State  law"  is 
inserted,  but  not  to  the  exclusion  of  possible  local  ordinances.  The  circulars  wTere 
uniformly  addressed  "City  Registrar  of  Vital  Statistics,"  and  in  some  instances  there 
is  no  such  official,  returns  being  made  under  the  county  system. 

Publications  are  indicated  as  follows:  a  =  annual  report;  b  =  biennial  report; 
w  =  weekly  bulletin;  m  =  monthly  bulletin;  q  =  quarterly  bulletin.  The  Bureau 
of  tJie  Census  desires  to  preserve  complete  files  of  all  official  publications  containing  vital 
statistics  in  the  United  States.  It  is  requested  that  registration  officials  noting  omission  of 
their  publications  urill  kindly  correct  this  list  and  regularly  transmit  copies  of  all  reports 
and  bulletins  to  the  Library  of  the  Census;  penalty  labels  will  be  provided  for  this  purpose 
upon  request. 

Registration  states,  and  registration  cities  in  nonregistration  states,  which  make 
returns  of  deatlis  directly  to  this  Bureau,  are  designated  by  asterisks  (*)  before  each 
name.  Registration  cities  in  registration  states,  whose  returns  are  received  through 
their  respective  state  offices,  are  indicated  by  daggers  (f). 

(71) 


STATES  AND  CITIES. 

(Reports  and  bulletins  —  see 
explanatory  note,  p.  71.) 

Estimated 
population, 
1906. 

State  law  or  city 
ordinance. 

Name  and  official  title  of  registrar. 
(  Remarks.  ) 

ALABAMA  (a)1  
Anniston 

2,017,877 

10,919' 
45,869 
8,110 
42,903 
40,808 
12,047 

1,421,574 

State  law 

W.  H.  Sanders,  M.  D.,  State  Health  Offi- 
cer, Montgomery. 

"  Unclaimed." 
D.  T.  Rogers,  Secretary  Board  of  Health. 

I.  C.  Skinner.  M.  D.,  Registrar. 

D.  B.  Sparks,  City  Clerk. 
F.  M.  Oliver,  Citv  Clerk. 

State  law 

Birmingham  

State  law. 

Huntsyille 

State  law 

^Mobile 

City  ordinance. 
State  law 

Montgomery  
Selma  (m) 

Both 

ARKANSAS  

Fort  Smith 

23,  505 
11,157 
39,  959 
13,038 

Both 

Hot  Springs    

Little  Rock  (am)2  

City  ordinance. 

Pine  Bluffs  

None. 

N.  K.  Foster,  M.  D.,  Secretary  State  Board 
of  Health  and  Registrar  of  Vital  Statis- 
tics, Sacramento. 
L.  W.  Stidham,  M.  D.,  Citv  Physician. 
.1.  J.  Benton,  M.  D.,  Health  Officer. 
T.  M.  Hayden,  M.  D.,  Health  Officer. 
L.  M.  Powers,  M.  D..   Health  Officer. 
E.  W.  Ewer,  M.  D..  Health  Officer 
S.  P.  Black,  M.  D.,  Health  Officer. 
H.  L.  Nichols,  M.  D.,  Health  Officer. 
F.  H.  Mead,  M.  D.,  Health  Officer. 
J.  T.  Watkins,  M.  D.,  Health  Officer. 
J.  C.  Corcoran.  Assistant  Secretary  Board 
of  Health. 

H.  L.  Taylor,  M.  D.,  Secretary  State  Board 
of  Health,  Denver. 

W.  H.  Sharpley,  M.  D.,  Health  Commis- 
sioner. 

J.  H.  Townsend,  M.  D.,  Secretary  State 
Board  of  Health,  Hartford. 
A.  P.  Kirkham,  City  Clerk. 
J.  N.  Booth,  Town  Clerk. 
Town  Clerk. 
C.  P.  Botsford,  M.  D.,  Registrar  of  Vital 
Statistics. 
S.  M.  Benton,  Town  Clerk. 
H.  Hess,  City  Clerk. 
W.  C.  Howard/Town  Clerk. 
H.  Heanes,  Town  Clerk. 
L.  D.  Penfield,  Town  Clerk. 
J.  J.  Carr,  Registrar  of  Vital  Statistics. 
F.  L.  Kenvon,  Town  Clerk. 
C.  S.  Holbrook,  Town  Clerk. 
W.  F.  Waterburv,  Town  Clerk. 
W.  W.  Bierce,  Town  Clerk. 
F.  P.  Brett,  Registrar  of  Vital  Statistics. 
F.  P.  Fenton,  Town  Clerk. 

A.  Lowber,  M.  D.,  Secretary  State  Board 
of  Health,  Wilmington. 
J.  Wigglesworth.  Registrar  of  Vital  Sta- 

W.  C.  Woodward,  M.  D.,  Health  Officer, 
Washington. 

J.  Y.  Porter,  State  Health  Officer,  Jack- 
sonville. 
C.  D.  Taylor,  Clerk  Board  of  Health. 

L.  G.  Avmard,  Clerk  Board  of  Health. 
J.  A.  Borns.  M.  D..  Citv  Physician. 

CALIFORNIA  (bm)  
(•Alameda  (a)  

1,648,049 

19,  644 
19,700 
13,  460 
(4) 
73,  812 
14,378 
31,022 
19,  140 
(4) 
23,  564 

19,354 
615,  570 

29,338 
10,147 
151,920 

13,  697 
30,  824 

1,005,716 

14,085 
84,  274 
16,  537 
95,  822 

12,029 
25,880 
9,937 
13,  133 
33,722 
121,227 
19,822 
19,759 
17,599 
10,808 
61,903 
9,111 

194,  479 
85,  140 
307,  716 

629,  341 

36,  675 
21,  174 
22,256 
24,220 

State  law  
State  law 

(•Berkeley 

State  law  
State  law  
State  law 

(•Fresno  

("Los  Angeles  (am) 

(•Oakland  (am)  

State  law  
State  law5  
State  law  «  
State  law  
State  law 

(•  Pasadena  . 

(•Sacramento  (m)  

San  Diego  (m)  
'San  Francisco  (am) 

•San  Jose  

State  law  
State  law 

(•Stockton 

*COLORADO  (b  in) 

State  law  

State  la\v  
State  lav. 

(•Colorado  Springs  (m)  

'Cripple  Creek  town 

(•Denver  (a)  

Both  
State  law 

(•Leadville 

(•  Pueblo  (m)  

State  law  
State  law  

CONNECTICUT  (am)... 
(•Ansonia  

State  law 

(•Bridgeport  (m)  7 

State  law 

Danbury  

State  law  . 

(•Hartford  (am)..  .. 

State  law 

Manchester  town  (m)  
(•Meriden  (a)  .. 

State  law  

State  law 

fMiddletown  town  

State  law  
State  law 

fNaugatuck  borough 

[•New  Britain 

State  law  
State  law 

fNew  Haven  (am)  

[•New  London 

State  law 

[•Norwich  

State  law*  
State  law 

^Stamford  

[•Torrington  town 

State  law 

[•Waterburv  

State  law  
State  law  

State  law 

[•Will  iman  tic 

DELAWARE  (b)  

"Wilmington  (a) 

City  ordinance  . 
(9) 
State  law 

*DlSTRICT    OF    COLUM- 
BIA8 (aw). 

FLORIDA  (am)  
"Jacksonville  (m  )  

City  ordinance  . 
City  ordinance  . 
City  ordinance  . 
City  ordinance  . 

'Key  West  

Pensacola 

Tampa  .. 

1  None  issued  since  1894. 

2  Reports  made  by  city  physician. 

3  No  record  is  kept  of  deaths.    Burials  (in  city  cemeteries)  are  recorded,  showing  cause  of  death,  etc. 
*  No  estimate. 

5  City  ordinance  also,  but  simply  supplemental. 

6  And  city  charter. 

7  Published  by  Board  of  Health,  E.  A.  McLellan,  M.  D.,  Health  Officer. 

8  Coextensive  with  city  of  Washington. 

9  Registration  is  effected  under  an  ordinance  of  the  late  board  of  health,  duly  legalized  by  Congress. 


73 


STATES   AND  CITIES.  Estimated     Stfttelaworpltv 

(Reports  and  bulletins-see  Population.       SiES! 
explanatory  note,  p.  71. ) 


Name  and  official  title  of  registrar. 
(Remarks.) 


GEORGIA      

2,443,719 
11,211 

L.  Thornton,  Clerk  Board  of  Health. 
E.  C.  Goodrich,  M.  D.,  Secretary  Health 
Department. 
J.  A.  Butts,  M.  D.,  Health  Officer. 
M.  M.  Moore,  Secretary  Board  of  Health. 
T.   L.   Massenburg,  Secretary    Board    of 
Health. 

J.  A.  Egan,  M.  D.,  Secretary  State  Board 
of  Health,  Springfield. 
G.  Gray,  City  Clerk. 
C.  W.  Geyer,  M.  D.,  Health  Officer. 
G.  H.  Beineke,  Citv  Clerk. 
H.  E.  Rhoads,  City  Clerk. 

None. 
M.  0.  Heckard,  M.  D.,  Registrar  of  Vital 
Statistics. 
"  Name  not  found  in  Directory." 
A.  Leach,  City  Clerk. 

W.  F.  Sylla,  City  Clerk. 

None. 
G.  E.  Baxter,  M.  D.,  Health  Officer. 
M.  Beescheid,  City  Clerk. 

B.  B.  Cole,  City  Clerk. 
A.  H.  Arp,  M.  D.,  Health  Commissioner. 
F.  Mendel,  Citv  Clerk. 
F.  C.  Gale,  M.  D.,  Health  Officer. 
J.  F.  Wolf,  Registrar  of  Vital  Statistics. 
P.  W.  Reardon,  Health  Officer. 

J.  E.  Smith,  City  Clerk. 
W.  L.  Smith,  M.D.,  President  Board  of 
Health. 

J.  N.  Hurtv,  M.  D.,  Secretary  State  Board 

Athens  

*  Atlanta  (a) 

104,  984 
43,  125 

9,453 
17,800 
32,  692 

68,5% 

5,  418,  670 

16,  562 
26,  823 
18,756 
25,506 
13,  910 
11,054 
2,049,185 

21,  794 
24,  727 
40,  958 
25,199 
22,  949 
15,  100 
20,611 
16,  362 
32,  185 
16,  337 
10,668 
10,800 
10,  891 
11,301 
20,  478 
11,188 
9,  662 
66,  365 
39,108 
23,009 
36,  051 
38,933 
15,771 

12,  132 
2,  710,  898 

25,842 
8,976 
17,501 
19,  232 
63,  957 
50,947 

15,956 

11,047 
219,  154 
10,840 

12,  019 
19,238 

IT,  932 
24,030 

17,292 

27,  293 
20,  628 
11,648 
19,602 

44,605 
52,  805 
11,  393 

9,944 
10.045 

City  ordinance  . 
City  ordinance  . 

City  ordinance  . 
City  ordinance  . 
City  ordinance  . 

City  ordinance  . 
State  law 

Augusta  (a) 

Brunswick  (a). 

finlilTnb'ls  (am) 

Macon  (m)  

Savannah 

ILLINOIS  (am) 

Alton  (m)  

State  law.  ... 

*  Aurora  (a) 

State  law 

"Belleville  

City  ordinance  . 
State  law 

Bloomington  (a  m) 

Cairo  

State  law  

Champaign  

State  law 

•'Chicago  (a  w) 

Both 

Danville  

State  law 

*Decatur 

State  law 

East  St.  Louis  

State  law  .  .  . 
Both 

Elgin      

Evanston  

State  law  . 
State  law 

Freeport 

Galesburg 

State  law 

••Jacksonville  (m)  .. 

City  ordinance  . 
State  law 

Joliet  

Kankakee  -  

State  law  .... 

Kewanee 

State  law 

Lasalle  

State  law  

Lincoln  .              .... 

State  law 

Mattoon 

<'itv  ordinance. 
State  law  
State  law 

Moline  

•Ottawa 

Pekin  

Both  

State  law 

Pporin.  (a.  m) 

"Quincy  (a)  

City  ordinance  . 
State  law 

Rock  Island.                    

Rock  ford  (m) 

State  law  
State  law 

"Springfield  (am)  

Streator  (a) 

State  law  
State  law 

Waukegan 

*!NDIANA  (a  m)  

State  law 

[•Anderson 

State  law  
State  law 

of  Health,  Indianapolis. 

T.  G.  Wilkinson,  City  Clerk. 

J.  J.  Casey,  Chief  Sanitary  Officer. 
H.  O.  Brueggeman,  M.  D.,  "Secretary  Board 
of  Public  Health. 
J.  T.  Clark,  M.  D.,  Secretary  Board   of 
Health. 
None. 
E.  Buehler,  M.  D.,  Health  Officer. 
W.  H.  Sheets,  M.  D.,  Secretary  Board  of 
Health. 

J.  D.   Hillis,   M.  D.,  Secretary  Board  of 
Health. 

O.  W.  McQuown,  M.  D.,  Secretary  Board 
of  Health. 
V.  V.  Bacon,  M.  D.,  Secretary  Board  of 
Health. 
H.  R.  Spickerman,  M.  D.,  Health  Officer. 
C.  C.  Funk,  M.  D.,  Health  Officer. 

C.  S.  Bond,  M.  D  ,  Secretary  Board  of 

[•Columbus  

(•Elkhart 

State  law 

•Elwood 

State  law 

•Evansville  (a  m) 

State  law 

[•Fort  Wayne  (a)  

State  law  
State  law 

[•Hammond  (a) 

|-Huntington 

State  law  
State  law  

[•Indianapolis  (a)  

[•Jeffersonville  

State  law 

(•Kokomo  

State  law 

[•Lafayette  (a  m)  ..     .. 

State  law 

[•Logansport  

State  law 

[•Marion  (a) 

State  law 

^Michigan  City  

State  law  
State  law 

[•Muncie  (a)  

[•New  Albanv... 

State  law 

[•Peru. 

State  law  
Both 

^Richmond  (aq)  
[•South  Bend  (a) 

State  law  
State  law 

Health. 
D.  W.  McNamara,  M.  D.,  Health  Officer. 

P.   H.   Caney,  M.  D.,  Secretary  Depart- 
ment of  Public  Health. 
N.  H.  Thompson,  M.  D.,  Health  Officer. 
"Returned." 

[•Terre  Haute  

[•Vincennes  (a) 

Both  

State  law 

fWabash  .. 

[•Washington... 

State  law  .  .  . 

74 


STATES   AND  CITIES. 

(Reports  and  bulletins—  see 
explanatory  note,  p.  71.  ) 

Estimated 
population, 
1906. 

State  law  or  city 
ordinance. 

Name  and  official  title  of  registrar. 
(Remarks.) 

IOWA  (b  m) 

2,205,690 

9,596 
25,  741 
29,380 
22,768 
25,117 
40,  706 
78,  323 
43,070 
14,810 
8,665 
14,  597 
12,100 
15,290 
10,288 
20,548 

42,  520 
18,  849 

1,612,471 

18,  871 
9,413 
12,  633 
13,024 

77,  912 

12,  123 
22,167 

15,964 
41,886 
35,541 

2,320,298 

8,428 
46,436 
10,  447 
15,  201 
29,  249 
226.  129 
30,  329 
14,  461 
22,  464 

1,539,449 

11,743 
314,  146 

17,  831 

714,494 

13,971 
12,  379 
23,500 
11,  527 
17,  165 
24,  997 
55,  167 
8,150 
10,899 

1,275,434 

9,077 
553,  669 

19,768 

9,956 
15.673 

State  law 

L.   A.   Thomas,    M.   D.,   Secretary    State 
Board  of  Health,  Des  Moines. 

J.  P.  Harrell,  M.  D.,  Health  Officer. 
None. 

N.  J.  Rice,  M.  D.,  Health  Officer. 
None. 

Boone  

State  law  

Burlington  (am) 

State  law  
State  law  

Cedar  Rapids  

Clinton 

State  law  
Both  
St^te  law  

Council  Bluffs  (am)  
Davenport  

Des  Moines  (a)  . 

State  law 

E.  A.  Linehan,  City  Recorder. 

H.  T.  Moore,  Clerk  of  Council. 
J.  D.  Fulliam,  M.  D.,  Health  Officer. 

J.  A.  Hull,  M.  D.,  Physician  to  Board  of 
Health. 
G.  J.  Ross,  M.  D.,  City  Health  Officer. 

S.  J.  Crumbine,   M.  D.,   Secretary  State 
Board  of  Health,  Topeka. 

None. 
J.  O.  Brown,  City  Clerk. 
None. 
E.  J.   Lutz,   M.   D.,   Secretary  Board    of 
Health. 
F.  D.  Brooks,  Secretary  and  Treasurer  of 
Cemeteries. 
J.  F.  Wallace,  M.  D.,  Secretary  Board  of 
Health. 

M.  R.  Mitchell,  M.  D.,  City  Physician. 
R.  M.  Dorr,  City  Clerk. 

W.  H.  Philips,  City  Clerk. 

B.  L.  Powell,  Citv  Clerk. 
J.  E.  Cassidy,  City  Clerk. 
G.  A.  Schneider,  Registrar, 
(i.  \V   Brown   M   D    Health  Officer 

Dubuque  (m)1 

City  ordinance  . 
State  law  
State  law 

Fort  Dodge 

Fort  Madison 

Keokuk  (m)  

State  law  
State  law  . 

Marshalltown  

Muscatine  (a) 

Both 

Oskaloosa  

State  law  

Ottumwa  (m)  .. 

(-) 
State  law  

Sioux  City  

Waterloo  

State  law  . 

KANSAS  (b  m)  

State  law  

Atchison 

State  law  . 

Emporia  

State  law  

Fort  Scott  3  

City  ordinance  . 
State  law  
City  ordinance  . 

City  ordinance  . 
Both 

Hutchinson 

Kansas  Citv  (a)  

Lawrence 

*T/eHVfTi  worth  (am) 

Pittsburg  

State  law  . 

Topeka 

City  ordinance  . 
Both  

*Wichita  

KENTUCKY  

Bowling  Green  (a)  

City  ordinance  . 
City  ordinance  . 

*Covington  (a) 

Frankfort  

Heriderson  (a)  . 

Both 

Lexington  (a) 

City  ordinance  . 
City  ordinance  . 
City  ordinance 

*Louisville  (a)              

*Newport  (aw) 

Owensboro  

None  

None. 
N.  F.  Graves,  M.  D.,  Health  Officer 

*Paducah  (a) 

City  ordinance  . 
State  law  

LOUISIANA  (b)  

W.  S.  Ingram,  M.  D.,  Secretary  State  Board 
of  Health. 
L.  J.  Granary,  City  Auditor. 
W.  F.  O'Reiflv,  M.  D.,  Chairman  Board  of 
Health. 
L.  H.  Pirkle,  M.  D.,  Secretary  Board  of 
Health. 
A.  G.  Young,  M.  D.,  Secretary  State  Board 
of  Health  and  Registrar  of"  Vital  Statis- 
tics. 
G.  W.  Bumpus,  City  Clerk. 
E  E  Newbert  City  Clerk 

Baton  Rouge 

Both 

*New  Orleans  (b  m  ^  : 

State  law  . 

Shreveport  (a  w  m) 

State  law  
State  law 

*MAINE  (a  m) 

State  law 

fAugusta 

State  law 

fBangor  (a)  

State  law  

V.  Brett,  City  Clerk. 
A.  J.  Grassy,  City  Clerk. 
A.  O.  Marcille,  City  Clerk. 

F.  F.  Driscoll,  Citv  Clerk. 
A.  L.  Orne,  City  Clerk. 
F.  W.  Clan,  City  Clerk. 

M.  L.  Price,  M.  D.,  Secretary  State  Board 
of  Health,  Baltimore. 
W.  S.  Welch,  M.  D.,  Health  Officer. 
J.Bosley,  M.  D.,  Commissioner  of  -Health 
and  Registrar  of  Vital  Statistics. 
C.  H.  Brace,  M.    D.,   Secretary  Board    of 
Health. 
I.  J.  McCurdv,  M.  D.,  Health  Officer. 
L.  Petermau.Citv  Clerk. 

fBath  (a) 

State  law 

fBiddeford 

State  law 

fLewiston  

State  law 

t  Portland  (am) 

State  law  
State  law  

fRockland  (a)  

fWaterville    

State  law 

*MARYLAND  (a)  

State  law  

fAnnapolis  (m) 

State  law 

*Baltimore  (am)  

Both  

•(•Cumberland 

State  law  
Both  

fFrederick  (m)  

tHagerstown  .  .  . 

State  law  .  .  . 

1  Published  by  Board  of  Health,  Charles  Palew,  M.  D.,  Physician  to  Board. 

2  Resolution  of  Board  of  Health. 

3  "Ordinance  requires  doctors  and  undertakers  to  make  reports  of  deaths,  but  it  is  almost  ignored. 
Births  the  same." 


75 


STATES  AND  CITIES. 

(Reports  and  bulletins  —  seo 
explanatory  note,  p.  71.) 

EstiniMted 
population, 
1906. 

State  law  or  city 
ordinance. 

Name  and  official  title  of  registrar. 
(Remarks.) 

*MASSACHUSETTS  (a)  .  .  . 
Adams  town 

3,  043,  346 

12,756 
S,  713 
9,881 
12,  975 
15,  491 
602,  278 
49.  340 
24,  136 
98,544 
37,  932 

State  law  

State  law  
State  law 

Hon.  W.  M.  Olin,  Secretary  of  State,  Bos- 
ton. 
F.  H.  B.  Memton,  Town  Clerk. 
N.  E.  Collins,  Town  Clerk. 
T.  J.  Robinson,  Town  Clerk. 
F.  I.  Babcock,  Town  Clerk. 
L.  S.  Herrick,  Citv  Clerk. 
E.  W.  McGlenen,  City  Registrar. 
D.  C.  Packard,  City  Clerk. 
E.  W.  Baker,  Town  Clerk. 
E.  J.  Brandon,  Citv  Clerk. 
C.H.  Reed,  Citv  Clerk. 
J.  C.  Bucklev,  City  Clerk. 
J.  H.  Carr,  Town  Clerk. 
J.  Peale.Town  Clerk. 
J.H.Cannell,  Citv  Clerk. 
A.  B.  Brayton,  City  Clerk. 
W.  A.  Davis,  City  Clerk. 
F.  E.  Hemen  way,  Town  Clerk. 

J.J.  Somes,  City  Clerk. 
\V.  W.  Roberts,  City  Clerk. 
J.  F.  Sheehan,  City  Clerk. 

C.  J.  Corcoran,  City  Clerk. 
R.  L.  Carter,  Citv  Clerk. 
<;.  P.  Dadman.Citv  Clerk. 
.l.W.Att  well,  Citv  Clerk. 
J  P  Litch  Clerk  Board  of  Health. 

•  \rlingtonxtown  (a) 

State  law  

•Attleboro  town  

State  law  
State  la  \v  
State  law  •  
State  law 

Beverly  (a)          .... 

•Boston  (a  m)  J 

•Brookline  town  (a). 

State  law  
State  law  
State  law  

•Cambridge  (a)  

•Chicopee  (a) 

20,  396 
13,217 
9,167 
30,066 
105,  942 
33,  319 
11,597 
12,  252 
25,  989 
37,  961 
50,  778 
14,  763 
71.548 
14.  678 
95,  173 
78,  748 
38,  912 
14,106 
19,974 
14,  562 
12,  251 
9,633 
76,  746 
14,714 
37,  475 
21,  740 
20,  222 
13,413 
25,  648 
11,424 
28,  911 
13,112 
37,961 
70,  798 
11,  195 
75,  836 
30,  953 
10,  464 
26,  842 
8,660 
11,568 
10,  261 
13,871 
11,637 
14,432 
130,  078 

2,  584,  533 

11,194 
12,715 
14,  645 
24,039 
40,  587 
353,  535 
11,872 

State  law  
State  law  
State  law  
State  law 

Clinton  town  (a)  

'Danvers  town  (a)  . 

'Everett  (a) 

Fall  River          

State  law  

Fitchburg 

State  law  
State  law 

•Framingham  town  (a)  
'Gardner  town 

State  law  
State  law 

'Gloucester  (a) 

'Haverhill  (a) 

State  law  

Holyoke  (am) 

State  law 

'Hvde  Park  town  

State  law  

'Lawrence  (m^  s 

State  law  
State  law 

'Leomin^ter  town  (a) 

'Lowell  (a)                ... 

State  law  
State  law 

'Lynn  (a) 

Marlboro  (a) 

State  law 

P.  B.  Murphv,  City  Clerk. 
A.  P.  Joyce,  City  Clerk. 
W.  D.  Jones,  City  Clerk. 

J.  McManus,  Town  Clerk. 
D.  B.  Leonard,  City  Clerk. 
J  O  W  Little  City  Clerk 

Medford  

State  law  

'Mel  rose  (a) 

State  law  
State  law  
State  law  
State  law  
State  law 

Milford  town  -  

'Natick  town  (a) 

New  Bedford 

'Newton  (a)4 

State  law 

I.  F.  Kingsbury,  Citv  Clerk. 
C.  S.  Brooker,  City  Clerk. 
C.  D.  Chase,  Citv  Clerk. 
E.  M.  Poor,  Town  Clerk. 
W.  R.  N.  Barker,  City  Clerk. 
E.  Le  Brugen,  Town  Clerk. 
H.  A.  Keith,  Citv  Clerk. 

'North  Adams  (a)  

State  law  

Northampton  (a) 

State  law  
State  law  
State  law  
State  law  
State  law  .... 

Peabody  town  

Pittslield  (a) 

Plymouth  town  (a)  

•Quincy  (a)  .  . 

Revere  town  (a) 

State  law  
State  law 

A.  J.  Brown,  Town  Clerk. 
J   C  Entwisle  Agent  Board  of  Health. 

"Salem 

Somerville  (a) 

State  law 

F.  W.  Cook,  City  Clerk. 
W.  W.  Buckley,  Town  Clerk. 
E.  A.  Newell,  City  Clerk. 
E.  A.  Tetlow,  City  Clerk. 
C.  F.  Hartshorne,"  Town  Clerk. 
L.  N.  Hall,  City  Clerk. 
A.  F.  Richardson,  Town  Clerk. 
F.  E.  Critchett,  Town  Clerk. 
L  J   Upham  Town  Clerk 

Southbridge  town         

State  law  

•Springfield  (a) 

State  law 

Taunton  (a)  

State  law  

Wakefield  town  (ai  

j-Waltham  (a)  

State  law  
State  law  
State  law  
State  law 

rWare  town  (a)  
fWatertown  town  (a) 

fWebster  town 

State  law 

fWestfield  town 

State  law 

J.  A.  Raymond,  Town  Clerk. 
J.  H.  Finn,  Citv  Clerk. 
E.  H.  Towne,  City  Clerk. 

Hon.  G.  A.  Prescott,  Secretary  of  State, 
Lansing. 
J.  Mawdsley,  City  Clerk. 

R.  Granger,  Citv  Clerk. 
T.  Thome,  City  Recorder. 

H.  T.  Renshaw,  Registrar. 
T.  J.  Burke,  Citv  Clerk. 

{•Weymouth  town  (a)  

State  law  

rWoburn  (a)  
r  Worcester  (am)* 

State  law  . 

State  law 

*MICHIGAX  (a  m) 

State  law  
State  law  . 

tAdrian  

'Alpena 

State  law 

•Ann  Arbor  (  m  )  

State  law  
State  law  
State  law  
State  law 

fBattle  Creek 

tBavCitv  

[Detroit  (a)  

Escanaba.  .  . 

State  law... 

1  Monthly  bulletin  published  by  Health  Department,   Samuel  H.  Durgin,  M.  D.,  chairman:  and 
werkly  and  monthly  mortality  from  reports  of  the  Board  of  Health  in  Monthly  Bulletin  of  the  Sta- 
tistics Department,  published  quarterly,  by  Edward  M.  Hartwell,  Secretary. 

2  Monthly  bulletin  by  Board  of  Health,  J".  H.  Lawrence,  M.D.,  Health  Officer. 

3  By  Board  of  Health. 

*  Monthly  bulletin  by  Board  of  Health. 


76 


STATES  AND  CITIES. 

^Reports  and  bulletins  —  see 
explanatory  note,  p.  71.) 

Estimated 
population, 
1906. 

State  law  or  city 
ordinance. 

Name  and  official  title  of  registrar. 
(Remarks.) 

*MICHIGAN—  Cont'd. 
(•Flint  

15,  574 

State  law  

D.  E.  Newcombe  City  Clerk 

Grand  Rapids  (a  m).   . 

99,  794 

State  law  . 

J  Schriver  Secretary  Board  of  Health 

Iron  Mountain^ 

8  257 

State  law 

J   B  Calis  Citv  Clerk 

Ironwood  

10,  177 

State  law  

W.  D.  Snyder  Citv  Clerk 

'Ishpeming  .     .  . 

10,  807 

State  law 

J.  D  West  Citv  Recorder 

Jackson 

25  360 

State  law 

Kalaniazoo  (a)  

32,  472 

State  law  

J.  J.  Lew  Health  Officer 

•Lansing 

22,  172 

State  law 

M   F  Gray  City  Clerk 

(•Manistee  

11,  932 

State  law  

C.  A.  Gnewuch,  Citv  Clerk 

[•Marquette  (m)  .. 

10,  969 

State  law. 

H.  Siegel  Citv  Recorder 

•Menominee 

10,234 

State  law 

B  T   Phillips  M   D     Health  Officer 

(•Muskegon  

20,  937 

State  law  

P.  P.  Misner,  Citv  Recorder 

("Owosso  

9,369 

State  law 

A.  H.  Dumond  Citv  Clerk 

•Pontiac 

11  942 

State  law 

G   H  Drake  M  D     Health  Officer 

[•Port  Huron  (m)  

20,  464 

State  law     . 

'Saginaw 

48,  742 

State  law 

D  C  Bell   Citv  Clerk 

•Sault  Ste.  Marie  

11,894 

State  law  

•Traverse  Citv. 

12,  153 

State  law  . 

T.  H.  Gillis  City  Clerk 

MINNESOTA  (am)  
"Duluth  (am)  

2,  025,  615 
67,337 

State  law1  
State  law  .  .  . 

H.  M.  Bracken,  M.  D.,    Secretary    State 
Board  of  Health,  St.  Paul. 
D.  D.  Murray,  M.D.,  Health  Commissioner 

"Mankato  (a)  

''Minneapolis  (am) 

11,075 
273,  825 

Both  

State  law 

A.  O.  Bjelland,  M.  D.,  Health  Officer. 
A  M  Kriedt  Registrar  of  Vital  Statistic-- 

St  Cloud 

9  574 

State  law 

J  B  Dunn  M  D    City  Health  Officer 

"St.  Paul  (am) 

203,  815 

State  law 

G.A.  Renz  M  D   Commissioner  of  Health- 

Still  water  

12,  458 

State  law  

W.  H.  Pratt,  M.  D.,  City  Physician. 

"Winona  (a  m)  

20,458 

State  law  

D.  B.  Pritchard,  M,  D.,  Health  Officer 

MISSISSIPPI 

1  708  272 

Meridian 

20  503 

• 

Natchez  (b  m)2  

13,  476 

City  ordinance  . 

G.  T.  Eiseli,  City  Clerk. 

Vicksburg 

15,  710 

MISSOURI  

3,  363,  153 

Carthage 

10  280 

None 

None 

Hannibal 

12,  780 

Citv  ordinance 

A.  S.  Lilleman,  City  Clerk. 

Jefferson 

11  416 

State  law 

None 

Joplin  

35,671 

"Kansas  City 

182  376 

City  ordinance 

H.  L.  Ebert,  Secretary  Board  of  Health. 

Moberlv  

8,012 

None  

None. 

"St.  Joseph  (a) 

118,  004 

City  ordinance 

W.  H.  Hartigan,  Secretary  Health  Depart- 

"St. Louis  (aw)  

649,  320 

Both  

ment. 
P.  J.  Regan,  Citv  Register. 

Sedalia 

15  927 

C.  E.  Baker,  City  Clerk. 

Springfield 

24  119 

Webb  City. 

11,897 

None  

None. 

MONTANA  (b  m)  .. 

303,  575 

State  law  l  

T.  D.  Tuttle,  M.D.,  Secretary  State  Board 

Anaconda  (a) 

12  267 

Both 

of  Health,  Helena. 
II  W  Stephens,  M.  D.,  Health  Officer. 

Butte  (a)  

43,  624 

State  law  

C.  T.  Pigot,  M.  D.,  Health  Officer. 

Great  Falls 

21  500 

State  law  . 

Helena 

16  770 

State  law 

J  S.  Tooker,  Secretary  Board  of  Health. 

NEBRASKA 

1  068  484 

State  law 

G.  H.  Brash,  M.  D.,  Secretary  State  Board 

"Lincoln  (m)  

48,  232 

Both  

of  Health,  Beatrice. 
W.  C.  Rohde,  Health  Officer. 

"Omaha  (a) 

124  167 

City  ordinance 

J.  Barker,  Registrar. 

South  Omaha  

36,  765 

Both  

-J.J.Gellev,  Citv  Clerk. 

*NEW  HAMPSHIRE  (a) 

432  624 

State  law 

I.  A.  Watson,  M.  D..  Secretary  State  Board 

[•Berlin  (a) 

11  982 

State  law 

of  Health  and  Registrar  of  Vital  Statis- 
tics, Concord. 
P.  J.  Smvth  City  Clerk. 

[•Concord  (a  m) 

21  210 

State  law 

H    E    Chamberlain     Registrar    of    Vital 

[•Dover  (a)           

13  459 

Both  

Statistics. 
F  E  Quimby  Citv  Clerk. 

[-Keene  (a)  

10,  197 

State  law  

F.  H.  Whitcomb,  Citv  Clerk. 

KLaconia  (a) 

8  042 

State  law  

J.F.Frank,  Citv  Clerk. 

(•Manchester  (m)  3 

64  703 

State  law 

E  C  Smith   Citv  Clerk. 

[•Nashua  (a)            . 

26,  652 

State  law  

A.L.  Cvr,  Citv  Clerk. 

["Portsmouth 

11  123 

State  law 

L  Hilton,  Citv  Clerk. 

[•Rochester  (a)... 

9.108 

State  law  .  .  . 

H.  L.  Worcester,  Citv  Clerk. 

i  New  law  in  effect,  1907. 

-Semimonthly. 

« Published  by  Board  of  Health. 


77 


STATES  AND  CITIES. 

(Reports  and  bulletins  —  see 
explanatory  note,  p.  71.) 

Estimated 
population, 
1906. 

State  law  or  city 
ordinance. 

Name  and  official  title  of  registrar. 
(Remarks.) 

*NEW  JERSEY  (a) 

2  1%  237 

State  law 

H  Mitchell   M  D    Secretary  State  Board 

[Atlantic  City  (a) 

39  544 

State  law  .     . 

of  Health,  Trenton. 
A.T.Glenn,  Registrar  of  Vital  Statistic^ 

rBayonne                

44,  170 

State  law  

PBloomfield  town 

12  068 

State  law  

W.   L.  Johnson,  Registrar  of  Vital  Sta- 

[Bridgeton 

13,  682 

State  law  

tistics. 
F.  L.  Hewitt,  City  Recorder. 

rCamden 

84  849 

State  law  . 

I.  V.  Bradley,  City  Clerk. 

^  East  Orange  (a)  

25,909 

State  law  

L.  E.  Rowley,  City  Clerk. 

rEli/abeth 

62  185 

State  law  

J.F.Kenah,  City  Clerl$. 

11  429 

State  law 

W.  P.  Ellery  Assessor 

^Harrison  town  (am) 

13,268 

State   law  and 

C.  J.Roonev,  Clerk  Board  of  Health  and 

fHoboken  (a)                < 

66  689 

county    ordi- 
nance. 
State  law  . 

Vital  Statistics  of  Hudson  County.    See 
Jersey  City. 
J.  Tucker,  Registrar  of  Vital  Statistics. 

[Jersev  City  (am)  

237,  952 

State  law   and 

C.J.Rooney,  Clerk  Board  of  Health  and 

[Kearnv  town  (m)  

14,  142 

county    ordi- 
nance. 
State  law  

Vital  Statistics  of  Hudson  County. 
C.  Schiller,  Registrar  of  Vital  Statistics. 

[Long  Branch 

12  525 

State  law 

E.B.Blaisdell,  Secretary  Board  of  Health 

Millville  

12,  144 

State  law  

and  Registrar. 
L.  H.  Hogate,  City  Recorder. 

•Montclair  town  (a) 

16  851 

Both 

C.  H.  Wells,  Health  Officer 

•Morristown  town  (a  )  
•New  Brunswick 

12,  322 
23  758 

City  ordinance  . 
Both 

D.  H.  Wilday,  Registrar  of  Vital  Statistics. 
J.  A.  Morrison   Citv  Clerk. 

Newark  (aw)  ...     .1  

289,  634 

State  law  

J.  F.  Connelly,  Citv  Clerk. 

Orange 

26  493 

State  law 

W.  B.  Gano,  City  Clerk. 

Passaic  (a)  

39,  799 

Both  

G.  F.  Grear,  Registrar  of  Vital  Statistics. 

•Paterson  (am) 

112  801 

State  law 

C.  S.  Gall,  Registrar  of  Vital  Statistics. 

Perth  Ambo  v  

27,534 

State  law  

C.  M.  MacWilliam,  Citv  Clerk. 

•Phillipsburg  town  

13,  712 

State  law  

Plainneld  (a) 

19  088 

State  law 

Miss  H.  O.  Mattison    Registrar  of  Vital 

j-Trenton  (a) 

86,355 

State  law 

Statistics. 
T.  B.  Holmes  c/o  Board  of  Health  Office. 

f  Union  town  

17,369 

State  law  and 

See  Jersey  City. 

[West  Hoboken  town  

30,280 

county   ordi- 
nance. 
State  law  

*NEW  YORK  (am)  
*  Albany  (a)  

8,  226,  990 
98,  537 

State  law  
City  ordinance  . 

E.  H.  Porter,  M.  D.,  Secretary  State  Board 
of  Health,  Albany. 
W.  G.  Van  Zandt,  Registrar  of  Vital  Sta- 

f Amsterdam 

24  172 

State  law 

tistics. 
S     W    Brumlev    Registrar  of  Vital  Sta- 

! Auburn  (a  m) 

32  963 

State  law 

tistics. 
A.  H.  Brown  M.  D.,  Health  Officer. 

Batavia  village  

10,400 

State  law  

E.  J.  Hogan,  Registrar  of  Vital  Statistics. 

Binghamton  (a)  . 

43,  785 

State  law     . 

J.  T.  Lamm,  Secretary  Board  of  Health. 

"Buffalo  (a) 

381  819 

Both 

F  C  Gram    M  D    Registrar  of  Vital  Sta- 

[Cohoes . 

24  093 

State  law 

tistics. 

Ktorning  

13,  913 

Both  

E.  W.  Byran,  M.  D.,  Health  Officer. 

Portland  (a)  

11,530 

State  law 

E.  S  Dalton  City  Clerk. 

fDunkirk  (am)  

15,  913 

Both  

L.  N.   Murrav,   Registrar   of   Vital   Sta- 

f-Elmira 

35  734 

State  law 

tistics. 
S.  A     Warner     Registrar   of  Vital    Sta- 

f Geneva  

12  506 

State  law 

tistics. 
J   M   O'Malley,  Citv  Clerk. 

[Glens  Falls  village  

15,  057 

State  law  .  .  . 

D.  I.  Howe,  Registrar  of  Vital  Statistics. 

[Gloversville  

18,  624 

State  law 

[Hornellsville  (m) 

13  390 

State  law 

B    R    Hollands    Registrar  of  Vital  Sta- 

^Hudson   

10  531 

State  law 

tistics. 
L  Van  Hoesen  M.  D.   Registrar  of  Vital 

[Ithaca 

14  768 

State  law 

Statistics. 
W  O   Kerr  Secretary  Board  of  Health 

Jamestown 

26  628 

State  law 

C  B  Jones  Registrar  of  Vital  Statistics. 

f  Johnstown  

9,  692 

State  law  . 

F.  Bogaskie,  Citv  Clerk. 

f  Kingston  (m) 

25  585 

State  law 

W.  B  Scott  Secretary  Board  of  Health. 

Little  Falls 

11  169 

State  law 

J  G  Hazlett  Registrar  of  Vital  Statistics. 

J-Lockport  

17  597 

State  law 

J.  R.  Compton,  Registrar. 

f-Middletown  (am)  

15,914 

State  law  

J.  G.  Grav,  Registrar  of  Vital  Statistics. 

[Mt.  Vernon  

25  670 

State  law 

A.  T.  Banning  M.  D.,  Health  Officer. 

•New  Rochelle 

21  520 

State  law 

W   B  Croft  Clerk  Board  of  Health. 

*New  York  (a  w  q)  

4,  113,  043 

Both  

W.  H.  Guilfov.  M.  D.,  Registrar  of  Records, 

Manhattan  borough  

2,  153,  495 

Both  

Department  of  Health. 
C.  J.  Burke,  M.  D  ,  Assistant  Registrar  of 

Bronx  borough 

285  809 

Both 

Records. 
A.J  O'Learv  M  D    Assistant  Registrar  of 

Brooklyn  borough...   . 

1,392,811 

Both 

Records. 
S.J.  Byrne,  M.  D.,  Assistant  Registrar  of 

Queens  borough  

206,806 

Both  

Records. 
R.Campbell,  M,  D.,  Assistant  Registrar  of 

Richmond  borough  .  . 

74,122 

Both 

Records. 
J   W   Wood   M  D.,  Assistant  Registrar  of 

Records. 

78 


STATKS   AND   CITIES. 

(Rej»orts  and  bulletins  —  see 
explanatory  note,  p.  71.) 

Kstimated 
population 
1906. 

State  law  or  city 
ordinance. 

Name  and  official  title  <»f  registrar. 
(Remark-.  , 

*NEW  YORK—  Con. 
fNewburg  (a) 

26,  593 

27,  827 
10,348 
14,842 
10,202 

22,419 
13,  768 

10,445 
9,757 
25,369 
185,  703 

17  726 

Both 

A.  P.  Templeton,  Registrar  of  Vital  sta 
tistics. 
W.  1'.  Home,  Registrar  of  Vital  Statistics, 
i  J.  H.  Tillitson,  Registrar  of  Vital  Sta  tistics. 
'  P>.  J.  Crichton,  jr.,  City  Clerk. 
T.  B.  Loughlen,  M.  D..  Registrar  of  Vital 
Statistics. 
E.  A.  Cooke,  Clerk  Board  of  Health. 
A.  Barger,  jr.,  Registrar  of  Vital  Statis- 
tics. 
T.F.Mannix.  Citv  Clerk. 
J.  F.  Clearv,  Citv  Clerk. 
E.  Burgess  City  Chamberlain. 
\V.  F.  Hitchcock,  Registrar  of  Vital  Sta- 
tistics. 
A.  T.Huggins,  Registrar  of  Vital  Statistics. 
C.  I.  Leggett.  Registrar  of  Vital  Statistics. 
D.  E.  Hart,  Citv  Clerk. 
J.Metz.  Registrar  of  Vital  Statistics. 
E.Bolton,  Registrar  of  Vital  Statistics. 
T.  W.  Fogartv,  Registrar. 
F.  W.  Streeter,  City  Clerk. 
F.  E.  Holahan,  City  Clerk. 
J.J.  Hanrahan,  Secretary  Board  of  Health. 

R.  H.  Lewis,   Secretary  State    Board   of 
Health,  Raleigh. 
A.  G.  Halvburton,  Citv  Clerk. 
F.  O.  Hawlev,  M.  D.,  Superintendent  of 
Health. 
E.  Harrison,    M.  D.,   Superintendent    of 
Health. 
F.  M.  Hahn,  Citv  Clerk. 
T.  P.  Sale,  Clerk  Board  of  Health. 
C.T.  Harper.  M.  D.,CitySuperintendehtof 
Health. 
Superintendent  of  Health. 

J.  Grassick,  M.  D.,  State  Superintendent 
of  Health,  Grand  Forks 

Hon.  C.  A.  Thompson,  Secretary  of  State, 
Columbus 
C.  O.  Probst.  M.  D..  Secretary  State  Board 
of  Health,  Columbus. 
A.  A.  Kohler,  M.  D..  Health  Officer. 
None. 
None. 

W.  T.  Ramsey.  M.  D..  Health  Officer. 
A    V   Smi'h    M    D     Health  Officer 

fNiagara  Falls  (a) 

State  law 

fNorth  Tonawanda  

State  law  

fOgdensburg  (a)  

State  law. 

tOlean  (a)  . 

State  law 

j-Oswego  (a)  

State  law.  . 

j-Peekskill  village 

State  law 

(Tlattsburg... 

State  law.. 

[•Port  Jervis 

State  law 

rPoughkeepsie  (a  i  
{•Rochester  (a  m) 

State  -law... 
Both  . 

Rome  (m) 

Both 

Saratoga  Springs  village  
Schenectadv  (a)  

13,117 
61,919 
118,880 
76,  513 
65,  096 
25,992 
14,  513 
64,110 

2,  059,  326 

18,414 
22,  009 

14,067 

9,840 
14,225 
21,528 

11,202 
463,  784 
13,097 
4,  448,  677 

50,738 
9,796 
15,  415 
9,912 
10,569 
38,440 
13,990 
345,  230 
460,  327 

145,  414 

State  law 

State  law  

Syracuse  (am) 

State  law 

Troy  (m)  . 

State  law 

Utica  (a)  

State  law  
State  law  
State  law 

VVatertown  (m) 

•Watervliet 

''Yonkers  (am).. 

Both  

NORTH  CAROLINA  (bm) 
\sheville 

State  law  

Stair  law 

Charlotte  (m) 

Both 

jTeensboro  (a) 

City  ordinance  . 

City  ordinance  . 
City  ordinance  . 
City  ordinance  . 

Both  

Newbern  . 

"Raleigh  (a  m^  

'Wilmington..  
Winston  (m)  

NORTH  DAKOTA  (b)  ... 
Fargo  • 

State  law  

% 

State  law 

OHIO  (a)  J  2 

(State  law 

[State  law  
State  law  

Akron  (m)  .. 

Alliance 

State  law. 

Ashtabula...  . 

State  law  
State  law 

Bellaire  (a) 

Cambridge  (a)3  

State  law.  
City  ordinance 
State  law 

Canton  (a) 

Chillicothe 

E.  F.  Waddle.  Health  Officer. 
H.  M.  Millar.  Registrar  of  Vital  Statistics 
F.  Combes,  Secretary  Public  Health  ]><•- 
partment. 
E.  G.  Horton,  M.  D.,  Health  Officer. 
C.E.Adams,  Clerk  Department  of  Health. 

None. 

A.    W.    Overmver,    Secretary    Board    of 
Health. 
M.  Millikin,  M.  D.,  Health  Officer. 

A.  L.  Jones,  M.  D.,  Health  Officer. 
E.  V.  Hutf.  M.  D..  Health  Officer. 
J.  M.  Bums,  M.  D.,  City  Health  Officer. 

None. 
F.  C.  Miller,  Health  Officer. 
G.  I).  Lummis.  M.  I)..  Health  Officer. 
C.  B.  Hatch.  M.  !>..  Health  Officer. 
Health  Officer. 
J.  W.  Bendt.  Clerk  Board  of  Health. 
II.  C.  Shoepfle.  M.  D..  Health  Officer. 
H.  Baldwin.  M.  I)..  Health  officer. 
None. 
H.  B.  Gibbon.  M.  D.,  Health  Officer. 

Cincinnati  (a  w)  . 

City  ordinance. 
City  ordinance 

State  law  
State  law 

Cleveland  (am)  

Columbus  (m) 

Dayton  (a) 

100,  799 
20,  078 
10,699 
17,613 
9,219 

27,  670 
12,186 
9,  855 
27,  702 
22,  730 
20,  142 
16,396 
14,001 
13,  054 
9,305 
20,  491 
18.  564 
20,714  i 
20,  378 
42,  069 
14,925 
11,078  1 

East  Liverpool  

State  law  

P^lvria 

State  law. 

Findlay 

State  law 

Fremont  (a  m)  . 

State  law  

Hamilton.  . 

State  law  
State  law  

Ironton  

Lancaster 

State  law 

Lima 

State  law 

Lorain  (a) 

State  law  
City  ordinance  . 
State  law  

Mansfield   

Marietta 

Marion 

State  law  
City  ordinance  . 
State  law  
State  law  
State  law  
State  law  
State  law 

Mnssillon  (a)  

Middletown  (al 

Newark  (m)  

Piqua                   ..  .. 

Portsmouth  (a)  

Springfield 

Both  

Steubenville 

State  law 

Tiffin  (a)  ... 

State  law... 

1  In  Statistics  of  Ohio  by  Secretary  of  State. 
-  In  Report  of  State  Board  of  Health. 
3  Report  to  State  Board  of  Health. 


79 


STATES  AND  CITIES. 

(Reports  and  bulletins—  see 
explanatory  note,  p.  71.) 

Estimated 
population, 
1906. 

State  law  or  city 
ordinance. 

Name  and  official  title  of  registrar. 
(Remarks.) 

OHIO—  Continued. 
*Toledo  (a  m) 

159,  980 

State  law  

J.  C.  Reinhart,  M.  D.,  Health  Officer. 

Warren 

10,  071 

State  law 

J.  H.  Jameson  Clerk  Board  of  Health 

Wellston 

10,247 

State  law  

None. 

9,356 

State  law. 

*Youngstown  (a)           

52,  710 

Citv  ordinance. 

G.   C.  Steventon,     Registrar     and    City 

24,856 

State  law 

Chemist. 
None. 

OKLAHOMA 

590,  247 

Guthrie 

13,  808 

City  ordinance. 

E.  W.  Kinnan,  City  Clerk. 

Oklahoma  Citv 

20  990 

None 

None. 

OREGON  (b  m) 

474,  738 

State  law 

R.   C.   Yennev     M.   D     Secretarv    State 

\storia 

9,  701 

State  law. 

Board  of  Health,  Portland. 
F.  V.  Mohn,  M.  D.,  Citv  Phvsician. 

*  Portland  (m)  

109,  884 

Citv  ordinance. 

E.  Moore,  Clerk  Board  "of  Health. 

*1>KNNSYI.VAM  A    (a)  

f  \llegheny  (am) 

6,928,515 
145,  240 

State  law  
State  law. 

W.  R.  Batt,  M.  D.,  State  Registrar  of  Vital 
Statistics,  Harrisburg. 
H.  K.  Beattv  M.  D.  Superintendent  Bu- 

f Allentown  (a) 

41,595 

Both  

reau  of  Health. 
J.    A.    McCafferty,    Secretarv    Board   of 

t  Altoo*na  (a  in  )  

47,  910 

State  law  

Health. 
S.  B.  Trees,  Secretary  Board  of  Health. 

•Beaver  Falls  borough  (in) 

10,  246 

State  law 

T  G.  McPherson  Registrar 

•Braddock  borough  

19,  218 

State  law  

L.  L.  Todd,  Registrar  of  Vital  Statistics. 

-(-Bradford  (a) 

16,  577 

Both  . 

J  C.  Walker  M.  D    Registrar 

•Butler  borough  (a) 

1"  1".") 

State  law 

T  M   Maxwell   M   D    Registrar  of  Vital 

fCarbondale  (a  m  ) 

14,  976 

Both 

Statistics. 
F  W   Lewis  Secretarv  Board  of  Health 

•Carlisle  borough      

10,  832 

State  law  

A.  Wiener,  Registrar  of  Vital  Statistics. 

•Chambersburg 

9,658 

State  law 

Chester  (ax    

38,002 

State  law  

H.  Harkson,  Registrar. 

'Columbia  borough  (a) 

13,  423 

State  law 

H   B  Clepper  Secretarv  Board  of  Health. 

•Danville  borough 

8  066 

State  law 

Dubois  borough  (a) 

11,313 

State  -law 

W.  J.  Smathers,  M.  D.   Registrar. 

Dunmore  borough 

15,145 

State  law 

'Duquesne  borough 

11,634 

State  law  

'Easton 

28  317 

State  law 

Erie  (a)                 

59,  993 

State  law      

.T.  W.  Wright,  M.  D.,  Health  Officer. 

'Harrisburg                       . 

55,  735 

State  law 

Hazelton  (a)    

'  15,  771 

State  law  

S.  J.  Hughes,  City  Clerk. 

Homestead  borough 

15,486 

State  law 

C.  C.  Huff  M    I).   Registrar  of  Vital  Sta- 

fJohnstown (am)           ..  .. 

43,  250 

State  law  . 

tistics. 
F.  H.  Singer.  Secretarv  Board  of  Health. 

Lancaster  (a) 

47,  129 

Both 

M   W   Raub  Registrar 

'Lebanon  (m)  

19,  404 

State  law  

E.  L.  Kreider,  Secretarv  Board  of  Health. 

McKeesport  (a) 

43,  438 

Stale  law 

A  J  Richards  Secretarv  Board  of  Health. 

Mahanov  City  borough  (a). 

14,  836 

State  law  

J.  H.  Kirchner,  Secretarv  Board  of  Health. 

Meadville  (a) 

11,769 

State  law 

Mt.  Carmel  borough  

16,  187 

State  law  

' 

•Nanticoke  borough  (a)  ... 

13,358 

State  law  

A.  Werth.  Health  Officer. 

'Newcastle  (am) 

36  847 

State  law 

C  C  Homer  Registrar  of  Vital  Statistics. 

Norristown  borough  (a  m). 

23,  747 

State  law  

C.  E.  White,  Registrar. 

Oil  Citv  (a) 

14  662 

State  law 

J   T  Fahey  Registrar 

tPhiladelphia  (a  w)  

1,441,735 

State  law  

G.  W.  Atherholt,  Chief  Division  of  Vital 

tPhoeuixville  borough  
[•Pitteburg  (m  w) 

9,604 
375,  082 

State  law  
State  law.  .  .. 

Statistics,  Bureau  of  Health. 
J    F.  Edwards,  M.  D.,  Superintendent  Bu- 

fPittston                         

13,906 

State  law  

reau  of  Health. 

fPlvmouth  borough  (am) 

16  235 

State  law 

R  J.  Williams  M   D.  Secretarv  Board  of 

fPottstown  borough 

13  942 

State  law  . 

Health. 
J   B.  Evans  Secretarv  Board  of  Health. 

t  Pott^vi  lie  borough 

16  664 

State  law 

fRi'ading  (a)  

91,141 

State  law  

F.  P.  Heine,  Secretarv  Board  of  Health. 

fScranton  (m) 

118  692 

State  law 

tshamokin  borough  (a)  

20  482 

Both  

T.  C.  Roberts,  Seoretarv  Board  of  Health. 

rSharon  borough 

11  909 

State  law 

tShonandoah  borough  

22,  949 

State  law  

[•South  Bethlehem  borough 
fb). 

fSteelton  borough 

15,005 
13,911 

State  law  
State  law  

S.  B.  Keener,  Secretary  Board  of  Health. 

fSunburv  borough 

10  968 

State  law 

B.  F  Heckert,  Registrar  of  Vital  Statistics. 

rTitugyiile  (a) 

8  346 

Both 

W.  Varian,  M.  D..  Health  Officer. 

t  Warren  borough  (a)  

10,  647 

State  law  

C.  W.  Schmehl,  M.  D.,  Registrar  of  Vital 

fWrst  Chester  borough  (a)  .. 
tWilkesbarre  (m)  .  . 

10,424 
60,  121 

State  law  
Both  .. 

Statistics. 
C.  E.  Woodward.  M.  D.,  Registrar  of  Vital 
Statistics. 
F.  H.  Gates,  Citv  Clerk. 

80 


STATES  AND  CITIES.  Estimated 


Name  and  official  title  of  registrar. 

,    D  AWknWlr-c<     \ 


explanatory  note,  p.  71.) 

1906. 

[  nemarKS.  ) 

*PENNSYLVANIA  —  Con. 
(•Wilkinsburg  borough 

16,949 

State  law 

W  Elder  Registrar 

(•Williamsport  (a)  .  . 

29,  735 

State  law  

R.  B.  staner,  Registrar. 

•York  (am)  

39,168 

State  law 

J.  H.  Bennett,  M.  D.   Subregistrar  of  Vital 

*RHODE  ISLAND  (a)  ... 

490,387 

State  law  

Statistics. 
G.  T.  Swarts,  M.  D.,  Secretary  State  Board 

(•Central  Falls 

19  702 

State  law 

of  Health,  Providence. 
C  F  Crawford  City  Clerk 

(•Cranston  town  

18,415 

State  law  

D.  D.  Waterman,  Town  Clerk. 

(•Cumberland  town... 

9,469 

State  law.. 

[•East  Providence  town  

14,  072 

State  law  

Lincoln  town  

9,279 

State  law  

D.  D.  Johnston,  Town  Clerk. 

(•Newport  (w) 

25  559 

State  law 

D  Stevens  Citv  Clerk 

hPawtucket  

44,211 

State  law  

J.  W.  Rowe,  Citv  Clerk. 

Providence  (a)  

203,  243 

Both         .     . 

C.  V.  Chapin    M.  D     Superintendent  of 

\  Warwick  

25,  464 

State  law  

Health. 

(•Woonsocket  (a  m) 

32,  994 

State  law 

W   C   Mason  City  Clerk 

SOUTH  CAROLINA  

1,453,818 

"Charleston  (a)  

56,317 

Citv  ordinance  . 

J.  M.  Green,  M.  D.,  Health  Officer. 

Columbia  

24,564 

Both 

E.    C     McGregor     Secretarv    Board    of 

Greenville  

13,810 

Health. 

Spartanburg 

14  905 

Both 

H   E  Heinitsh  jr    Secretarv 

*SOUTH  DAKOTA  (a)... 

465,908 

State  law 

Hon.  Doane  Robinson,  Superintendent  of 

(•Sioux  Falls  

12,681 

Both  

Vital  Statistics.  Pierre. 
A.  H.  Tufts,  M.  D.,  Health  Officer. 

TENNESSEE 

2  172  476 

Chattanooga  (m) 

34  297 

Clarksville  

10,337 

City  ordinance  . 

R.  B.  Macon,  M.  D.,  Health  Officer. 

Jackson  .  .        ... 

17  193 

None 

None. 

Knoxville  (a)  l 

36  051 

Citv  ordinance 

W    R   Cochrane    M   D     Secretarv  Board 

"Memphis  (m) 

125  018 

City  ordinance 

of  Health. 

"Nashville  (am)  

84,703 

Citv  ordinance  . 

L.  B.  Smith,  M.  D.,  City  Health  Officer. 

TEXAS  (b) 

3  536  618 

State  law 

W  Brumbv    M   D     State  Health  Officer, 

Austin  

25  290 

State  law 

Austin. 

Beaumont 

13  105 

State  law 

None 

Corsicana  

12,275 

State  law  . 

Dallas 

52  793 

State  law 

. 

Denison  -  

12,  317 

State  law 

J.  D.  Yocorn,  Citv  Secretarv. 

El  Paso 

19  248 

State  law 

Fort  Worth  (a)  

27,096 

Citv  ordinance  . 

W.  J.  Estes,  Citv  Secretarv. 

"Galveston  (q)  .. 

34  355 

Citv  ordinance 

C.   W.   Trueheart,    M.    D".,    Citv    Health 

Houston  

58,132 

State  law  

Physician. 

Laredo 

14  695 

State  law 

Palestine  

9,773 

State  law  

None. 

Paris  

10  018 

Both 

M.  A.  Walker,  M.  D.,  Health  Officer. 

"San  Antonio  (m)  
Sherman  

62,  711 
11,989 

City  ordinance  . 
State  law  

Tyler  

8,765 

D.  H.  Connally,  M.  D.,  Health  Officer. 

Waco  

24,  430 

State  law  

UTAH  (m) 

316  331 

State  law 

T.  B  Beatty,  M.  D.,  Secretary  State  Board 

Ogden        

17  165 

State  law 

of  Health,  Salt  Lake  City. 

"Salt  Lake  Citv  (m  w) 

61  202 

Both 

M.  R.  Stewart,  M.   D.,    Health  Commis- 

*VERMONT (b) 

350  373 

State  law 

sioner. 
H.  D.  Holton,  M.  D.,  Secretarv  State  Board 

(•Barre  (a) 

11  028 

State  law 

of  Health,  Brattleboro. 
J.  Mackav,  Citv  Clerk. 

(•Burlington  (a) 

21  070 

State  law 

M.  C.  Grandy,  Citv  Clerk. 

(•Rutland  

11,961 

State  law  

H.  B.  Whittier,  City  Clerk. 

VIRGINIA 

1  973  104 

"Alexandria  (a) 

14,  642 

City  ordinance  . 

E.  F.  Price,  Auditor. 

Danville  (a  m) 

17  972 

City  ordinance 

J.  W.  Robinson,  M.  D.,  Health  Officer. 

"Lynchburg  

22,850 

Citv  ordinance  . 

"Not  in  city." 

Manchester  (a) 

9  997 

Both 

M.  P.  Rucker,  M.  I).,  President  Board  of 

Newport  News  

28,749 

Health. 

^Norfolk  (bin) 

66  931 

Both 

A.  P.  Pannill.  Asst.  Health  Commissioner. 

"Petersburg  (am)... 

21,810 

Citv  ordinance  . 

V.  L.  Weddell.  Secretarv  Board  of  Health- 

1  Monthly  bulletins  issued  until  1907. 

2  Record  kept  only  of  interments  in  city  limits. 


81 


STATES   AND  CITIES. 

(Reports  and  bulletins—  see 
explanatory  note,  p.  71.) 

Estimated 
population, 
1906. 

State  law  or  city 
ordinance. 

Name  and  official  title  of  registrar. 
(Remarks.) 

VIRGINIA—  Continued. 
Portsmouth  (m) 

18,  627 

State  law  

F.  S.  Hope,  M.  D.,  Health  Officer. 

*Richmond  (a  m) 

87  246 

City  ordinance  . 

J.  M.  Donahoe,  Registrar  of  Vital  Statis- 

Roanoke 

24,699 

tics. 

WASHINGTON  (b) 

614  625 

State  law 

E  E  Heg  M  D    Secretary  State  Board  of 

*Seattle  (m) 

104  169 

State  law 

Health.  Seattle 
C  Calhoun   M   D    Health  Officer 

*Spokane  (am)            

47,006 

Both  

M.  B.  Grieve,  M.  D.,  Health  Officer 

55  392 

State  law 

A    de  Y  Green    M    D.   Commissioner  of 

Wallawalla  (m)                .  ... 

13  253 

Both  

Health. 
A  E  Braden,  M.D.,  Health  Officer 

WEST  VIRGINIA  (b)  

1,076,406 

State  law  

H.  A.   Barbee,    M     D  ,    Secretary    State 

13  715 

City  ordinance 

Board  of  Health,  Point  Pleasant. 
J  S  Ross  City  Recorder 

Huntington                   ...  

13  015 

16  477 

City  ordinance 

C  W   Hudson   M  D    Health  Officer 

*Wheeling  (a  q)  

41,494 

Citv  ordinance  . 

W.  H.  McLain,  M.  D.,  Health  Officer. 

WISCONSIN  (b) 

2  260  930 

State  law  l 

C  A  Harper  M  D    Secretary  State  Board 

*Appleton 

17  383 

State  law 

of  Health,  'Madison. 
J  V  Canavan   M   D    Health  Officer 

Ashland               

14,  808 

State  law  

*Beloit  (q) 

13  339 

State  law 

H  O  Delaney  M  D    Health  Officer 

Chippewa  Falls  

9,192 

State  law  

None. 

*Eau  Claire 

18  981 

State  law 

J   F   Fair  M  D     Health  Physician 

Fond  du  Lac  '.  

17,719 

State  law  

None. 

*Green  Bay                       

23  688 

State  law 

H.   P.   Rhode     M     D.    Commissioner  of 

Janesville           

13,887 

State  law     .. 

Health. 
W  D.  Merritt.M.D  .HealthCommissioner. 

Kenosha                          .... 

17  061 

State  law 

None 

La  Crosse    

29,  115 

State  law  

Register  of  Deeds. 

*Madison 

25  128 

State  law 

O  S   Norsman   City  Clerk 

*Manitowoc  

12,922 

State  law  

I.  E.  Meany,  M.  D.,  Health  Officer 

*Marinette                        

15,  186 

State  law 

S  P.  Jones  M   D    Health  Commissioner 

Merrill 

9  329 

State  law 

None 

*Milwaukee  (a  m)    

317,  903 

State  law 

F.  E.  Darling    M.  D      Registrar  of  Vital 

Oshkosh      

31,033 

Both.. 

Statistics. 
A.  H.  Brocho,  M.  D.,  HealthCommissioner 

Racine                          

32  928 

Neither 

C  Harms  Acting  Health  Officer 

Sheboygan  (q) 

24  239 

State  law 

H    C    Reich     M     D     Commissioner    of 

Stevens  Point 

8  922 

State  law 

Health. 

37  643 

Both 

Watertown 

8,659 

State  law 

\Vausau 

14  879 

State  law 

WYOMING 

103  673 

Cheyenne 

13,  570 

City  ordinance 

W  A   Burgess  M    D     Health  Officer 

Laramie 

7  480 

State  law 

None 

1  New  law  in  effect,  1907. 


9159—07- 


».       ,  oc, 

[off.,    T.M.Reg.  U.S.  Pat.  Off. 


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